Every finding on record at Good Shepherd Village

Based on observations and resident and staff interviews, the facility failed to ensure meals were palatable and served at proper temperature. This had the potential to affect all 59 residents who receive their meals from the kitchen. Findings include:Interview on 06/22/26 at 3:47 P.M. with Resident #7 reported the food was terrible and most of the time it was cold, had no taste, and meats were tough.Review of the dinner menu for 06/24/26 revealed dinner was a chicken ranch wrap, side salad, vegetable soup, and a slice of yellow cake for dessert.Observations of holding temperatures at the start of dinner service on 06/24/26 at 5:07 P.M. revealed the chicken strips in the chicken ranch wrap were 170 degrees Fahrenheit (F) and the vegetable soup was 178 degrees F.Observation of the test tray at the end of dinner service and interview with Dietary Manager (DM) #158 on 06/24/26 at 6:20 P.M. revealed the chicken strips in the chicken ranch wrap were 83 degrees F and falling. The wrap was bland, cold and soggy. DM #158 confirmed the temperature of the chicken strips was outside of safe holding temperatures.This deficiency represents non-compliance investigated under Complaint Number 2576086.

Based on observation, record review, personnel file review, staff interview, and policy review, the facility failed to ensure staff completed proper hand hygiene during tracheostomy care and failed to ensure tuberculosis (TB) Mantoux screenings were completed according to the facility's TB Risk Assessment. This affected Resident #5 and had the potential to affect all 59 residents residing in the facility.Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 11/19/25. Diagnoses included non-traumatic intracranial hemorrhage and tracheostomy status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was unable to complete the Brief Interview for Mental Status (BIMS) assessment. Review of the physician orders revealed orders to cleanse the area around the tracheostomy and neck daily and apply a clean drain sponge daily, change the tracheostomy mask daily, change the tracheostomy collar tubing weekly by Advantage Respiratory Services, and maintain Enhanced Barrier Precautions (EBP) related to the resident's tracheostomy and gastrostomy tube. Review of the resident's care plan, last revised 05/28/26, revealed Resident #5 had a six-millimeter (mm) Shiley tracheostomy related to impaired breathing mechanics. Interventions included monitoring respiratory status each shift and providing daily tracheostomy care and care as needed. Observation on 06/22/26 at 3:33 P.M. revealed Respiratory Therapist (RT) #300 entered Resident #5's room wearing a gown and gloves to perform tracheostomy care. While wearing the same pair of gloves, RT #300 touched storage boxes, supply bins, and unopened supply packages located inside Resident #5's closet. Without removing or changing gloves, RT #300 opened the sterile tracheostomy care kit, removed clean gloves from the package using the contaminated gloves, opened sterile gauze packages, and poured sterile water onto the gauze. RT #300 then loosened the tracheostomy ties, removed the soiled drain sponge, and removed the inner cannula while continuing to wear the same gloves that had contacted environmental surfaces. RT #300 placed a second pair of gloves over the original contaminated gloves and inserted the new inner cannula. Sterile solution and cotton-tipped applicators were used to clean around the tracheostomy, followed by wet gauze to cleanse the site and dry gauze to dry the area. RT #300 then removed only the outer pair of gloves, leaving the original contaminated gloves in place. Using the original gloves, RT #300 wiped the tracheostomy site with dry gauze and handled a clean drain sponge before placing it beneath the tracheostomy. At no time during the procedure did RT #300 perform hand hygiene or remove and replace the original contaminated gloves after touching environmental surfaces and before handling clean supplies or performing tracheostomy care. During an interview on 06/22/26 at 3:46 P.M., RT #300 confirmed the observations described above, including that she did not perform hand hygiene or replace the original pair of gloves during the tracheostomy care procedure after contacting environmental surfaces before handling clean supplies and the resident's tracheostomy. Review of the facility policy titled Handwashing/Hand Hygiene, revised August 2019, revealed hand hygiene is the primary means of preventing the spread of infection. Staff should perform hand hygiene before performing non-surgical invasive procedures, before handling clean dressings or gauze, before donning sterile gloves, before moving from a contaminated body site to a clean body site, after contact with objects in the resident's immediate environment, after removing gloves, and after handling contaminated equipment or dressings. The use of gloves does not replace hand hygiene, staff must perform hand hygiene before applying gloves, and hand hygiene is required after glove removal. Review of the facility policy titled Tracheostomy Care Level III, revised August 2013, revealed aseptic technique must be used during tracheostomy care. The policy instructed staff to wash their hands before beginning the procedure, don examination gloves, remove the soiled dressing, remove and discard contaminated gloves, perform hand hygiene, apply fresh sterile gloves before replacing the inner cannula, remove and discard gloves after completion of the procedure, perform hand hygiene again, and document the resident's response. 2. Review of the personnel file for Certified Nursing Assistant (CNA) #112 revealed a hire date of 02/23/26. The employee's TB Mantoux screening revealed the first test was not read until 02/25/26. CNA #112 provided resident care prior to completion of the required pre-employment TB screening. Review of the personnel file for CNA #145 revealed a hire date of 01/16/26 and a start date providing resident care of 01/17/26. The employee's TB Mantoux screening revealed the first test was not read until 01/18/26. CNA #145 provided resident care prior to completion of the required pre-employment TB screening. Review of the personnel file for Licensed Practical Nurse (LPN) #146 revealed a hire date and start date of 12/01/25. The employee's TB Mantoux screening revealed the first test was not read until 12/03/25. LPN #146 provided resident care prior to completion of the required pre-employment TB screening. Review of the personnel file for LPN #108 revealed a hire date of 05/11/23. There was evidence of the required annual TB screening questionnaire was located in the employee's personnel file. Review of the personnel file for CNA #192 revealed a hire date of 11/21/23. There was evidence of the required annual TB screening questionnaire was located in the employee's personnel file. Review of the facility's TB Risk Assessment, dated April 2026, revealed newly hired healthcare personnel were to receive baseline TB screening upon hire and healthcare personnel were to complete annual TB symptom screening thereafter. Interview on 06/29/26 at 4:12 P.M. with Human Resource Director (HR) #136 confirmed CNA #112, CNA #145, and LPN #146 provided care to residents prior to their TB Mantoux was read. HR #136 confirmed LPN #108 and CNA #192 did not have their annual TB screening questionnaire completed according the facility's TB Risk Assessment.

Based on record review, staff interview, and facility policy review, the facility failed to maintain accurate documentation on the disposition of controlled substances. This affected one (Resident #20) of one resident reviewed for pain management. This had the potential to affect 31 residents at the facility who utilize controlled substances. The facility census was 59.Findings include:Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic pain. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had intact cognition and pain in thoracic spine.Review of Medication Monitoring/Control Records for Resident #20 revealed one Hydrocodone five milligrams (mg)/Acetaminophen (Scheduled II controlled substance) 325 mg tablet was removed from locked storage for Resident #20's administration six times on [DATE] at 6:00 P.M., [DATE] at 5:10 P.M., [DATE] at 10:34 A.M., [DATE] at 5:03 P.M., [DATE] at 1:48 P.M., and [DATE] at 9:30 A.M. Review of Resident #20's Medication Administration Record (MAR) revealed Hydrocodone five mg/Acetaminophen 325 mg was not documented as administered on [DATE] at 6:00 P.M., [DATE] at 5:10 P.M., [DATE] at 10:34 A.M., [DATE] at 5:03 P.M., [DATE] at 1:48 P.M., and [DATE] at 9:30 A.M. Review of the Medication Monitoring/Control Records for Resident #20 revealed eight tablets of Hydrocodone five mg/Acetaminophen 325 mg were recorded as waste (expired) on [DATE] and indicated these doses were transferred to other Disposal Record. Review of the facility's Record of Disposal lists six tablets of Hydrocodone five mg/Acetaminophen 325 mg for Resident #20 as destroyed by drug disposal bottle on [DATE].Interview on [DATE] at 4:10 P.M. with Assistant Director of Nursing (ADON) #148 confirmed there was no documentation in Resident #20's MAR that Hydrocodone five mg/Acetaminophen 325 mg was administered on [DATE] at 6:00 P.M., [DATE] at 5:10 P.M., [DATE] at 10:34 A.M., [DATE] at 5:03 P.M., [DATE] at 1:48 P.M., and [DATE] at 9:30 A.M. ADON #148 confirmed the discrepancy of number of tablets of Hydrocodone five mg/Acetaminophen 325 mg documented as wasted on the facility's Medication Monitoring/Control Records (eight tablets) and the facility's Record of Disposal (six tablets).Review of the facility policy titled Controlled Substances revised [DATE] revealed the facility (will comply) with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of controlled substances.The facility policy titled Administering Medications revised [DATE] revealed the individual administering the medication initials the resident's MAR after administering each medication.This deficiency represents non-compliance investigated under Control Number 2748117.

Based on record review and staff interviews, the facility failed to ensure a resident who had a history of septic shock and urinary tract infection (UTI) received physician ordered antibiotics to treat the UTI and seen by infectious disease as recommended on the hospital discharge orders. This affected one (Resident #67) of five residents reviewed for UTIs. The facility census was 59.Findings include:Review of Resident #67's medical record revealed an admission date of 06/06/25. Diagnoses included Alzheimer's disease, obstructive and reflux uropathy, sepsis, and benign prostatic hyperplasia. The significant change Minimum Data Set 3.0 (MDS) assessment completed 08/22/25 revealed Resident #67 had short- and long-term memory impairment, was not oriented to person, place, or time, and was dependent on staff assistance for all personal care.Review of the nursing progress notes revealed Resident #67 was hospitalized from [DATE] to 06/06/25 for septic shock secondary to catheter-associated urinary tract infection (CAUTI) and gastrointestinal bleed (GIB). Review of the discharge orders revealed they included to follow up with urology in one week for stent removal. Continue intravenous (IV) Ampicillin (antibiotic) two grams every four hours for UTI. Continue IV Ceftriaxone (antibiotic) two grams every 12 hours for five weeks for UTI, ending on 07/03/25; Follow up with infectious disease clinic one week after discharge.Review of the physician orders and medication administration record (MAR) for June 2026 revealed the order for IV Ceftriaxone (antibiotic) two grams every 12 hours for five weeks for UTI, ending on 07/03/25 was not administered according to physician orders on 06/06/25, 06/07/25, 06/08/25, and 06/09/25. On 06/06/25, 06/07/25, 06/08/25, and 06/09/25, Resident #67 received one grams (not two grams as ordered) intramuscularly (IM) twice daily (five doses). On 06/16/25, IV Ceftriaxone (antibiotic) two grams every 12 hours was stopped (despite orders to continue through 07/03/25.Review of a nursing progress note dated 06/09/25 (late entry, note created 06/22/25) stated a telephone call was placed to the infectious disease clinic and the clinic stated they will call back with the date and time of an appointment.The nursing progress note dated 06/19/25 revealed Resident #67's peripherally inserted central catheter (PICC) line was removed due to Resident #67 completed IV antibiotic therapy.The nursing progress note dated 06/19/25 (late entry, note created 06/22/26) stated the infectious disease clinic called back and scheduled Resident #67's follow up appointment for 06/25/25.The nursing progress note dated 06/20/25 revealed Resident #67 continued to show signs of a UTI. Resident #67's physician was contacted and received new orders to start Amoxicillin oral antibiotic 500 milligrams (mg) three times per day for seven days, with treatment ending on 06/27/25. On 06/21/25, the physician order changed from Amoxicillin oral antibiotic 500 mg three times per day to Ampicillin oral antibiotic 500 mg three times per day to match the previous antibiotic type. The progress notes revealed Resident #67 continued to show signs and symptoms of UTI and the antibiotic order was extended an additional seven days to be completed on 07/03/25.There was no indication Resident #67 went to Infectious Disease Clinic on 06/25/26 or at any time during Resident #67's stay at the facilty.Interview on 06/29/26 at 10:40 A.M. with Infectious Disease Clinic #700 confirmed Resident #67 was seen by the physician on 06/05/25 while he was in the hospital. The clinic confirmed Resident #67 was not seen for further appointments.Interview on 06/29/26 at 3;43 P.M. with Regional Director of Clinical Services (RDCS) #211 confirmed Resident #67's IV and IM antibiotic treatments for UTI and sepsis ended earlier than originally ordered by the infectious disease clinic. RDCS #211 confirmed Resident #67 did not receive the IV Ceftriaxone (antibiotic) two grams every 12 hours 06/06/25, 06/07/25, 06/08/25, and 06/09/25. RDCS #211 confirmed Resident #67 continued to show signs and symptoms of a UTI after completing IV and IM antibiotic treatments and was started on oral antibiotics. RDCS #211 confirmed Resident #67 had an appointment scheduled with the infectious disease clinic that he did not attend.This deficiency represents non-compliance investigated under Complaint Numbers 2576086, 2661156, and 2965086.

Based on observations, staff and resident interviews, medical record review, and policy review, the facility failed to ensure the resident's oxygen was being administered according to physician orders. This affected three (Residents #34, #47, and #75) of four residents reviewed for oxygen. The facility census was 59.Findings include:1. Review of the medical record for Resident #34 revealed an admission date of 05/08/23. Diagnoses included chronic pulmonary disease and heart failure. Review of the physician orders dated 08/15/25 revealed oxygen should be set to four liters via nasal cannula. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 intact cognition and was independent with most activities of daily living and mobility. Review of the plan of care dated 06/08/26 revealed Resident #34 was on oxygen therapy with interventions for oxygen settings of four liters delivered by nasal cannula. Observation and interview on 6/22/26 at 12:35 P.M. with Resident #34 revealed she thought she was supposed to be on about five liters of oxygen. The concentrator tank was observed to be set at 2.5 liters. Interview and observation on 06/22/26 at 1:02 P.M. with Licensed Practical Nurse (LPN) #215 confirmed the oxygen was set to 2.5 liters and verified the physician order stated it should be set to four liters. LPN #215 adjusted the oxygen level to four liters. 2. Review of the medical record for Resident #47 revealed an admission date of 04/30/26. Diagnoses included chronic obstructive pulmonary disease. The Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had intact cognition. Review of the Clinical admission assessment dated [DATE] revealed Resident #47 utilized continuous oxygen at two liters per minute via nasal cannula for a chronic respiratory condition. Review of physician orders revealed an active order dated 05/01/26 for oxygen at two liters per minute continuously via nasal cannula every shift. Observation on 06/22/26 at 3:09 P.M. revealed Resident #47 was receiving oxygen via nasal cannula. The oxygen concentrator was observed to be set at three liters per minute. Review of the physician order at the time of the observation confirmed the resident was ordered to receive two liters per minute. Interview with Licensed Practical Nurse (LPN) #141 on 06/22/26 at 3:09 P.M. confirmed the physician's order directed oxygen to be administered at two liters per minute and confirmed the oxygen concentrator was set at three liters per minute at the time of the observation. 3. Medical record review for Resident #75 revealed an admission date of 06/19/26. Diagnoses included acute on chronic diastolic heart failure, chronic obstructive pulmonary disease, and acute and chronic respiratory failure (COPD). Review of the physician order dated 06/19/26 revealed Resident #75 had an order for oxygen at two liters per minute. Review of the care plan last revised 06/23/26 revealed Resident #75 has altered respirator saturations and difficulty breathing related to COPD. Interventions included to administer oxygen as ordered. Observation on 06/22/26 at 2:29 P.M. revealed Resident #75 was receiving oxygen at 3.5 liters per minute. Interview on 06/22/26 at 2:54 P.M. with the Director of Nursing (DON) confirmed Resident #75 was receiving 3.5 liters per minute and his physician orders were to be administered at two liters per minute. Review of the facility policy titled Oxygen Administration Level III, revised October 2010, revealed staff were to verify physician orders before administering oxygen, review the resident's care plan, ensure the proper flow of oxygen was being administered, adjust the oxygen delivery device to the prescribed flow rate, observe the resident while receiving oxygen therapy, and document the oxygen flow rate, route, rationale, and resident response following oxygen setup or adjustment.

Based on record reviews, observations, and resident and staff interviews, the facility failed to ensure residents were served the appropriate diet. This affected one (Resident #12) of three residents reviewed for nutrition. The facility census was 59.Findings include:Review of the medical record for Resident #12 revealed an admission date of 03/26/26. Diagnoses included late onset Alzheimer's disease, type two diabetes mellitus, schizoaffective disorder, anxiety, and protein-calorie malnutrition.Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #12 had short and long term memory impairment and severely impaired decision-making. Resident #12 required setup assistance with meals, had no signs or symptoms of a swallowing disorder, had no natural teeth and did not wear dentures.Review of the physician orders dated 03/26/26 revealed Resident #12 was ordered a regular diet, mechanical soft texture, and thin liquids.Review of the care plan revealed Resident #12 was at risk for impaired nutritional status due to chronic disease process, taking diuretic and psychotherapeutic medications, having no natural teeth, and requiring a modified texture diet. Interventions included ensuring Resident #12 was provided and served a diet as ordered.Review of the dinner menu for 06/24/26 revealed dinner was a chicken ranch wrap, side salad, vegetable soup, and a slice of yellow cake for dessert. The mechanical soft option substituted the chicken ranch wrap for a chicken salad sandwich and the side salad for fork-mashable carrots.Observations during dinner service on 06/24/26 at 5:58 P.M. revealed Resident #12's meal ticket did not indicate her diet was mechanical soft texture. Resident #12 was served a chicken ranch wrap, side salad, vegetable soup, and a slice of yellow cake. Continued observations revealed Resident #12 ate the lettuce and yellow cake but did not eat anything else.Interview with Resident #12 on 06/24/26 at 5:58 P.M. confirmed she did not eat most of her dinner because it was too hard to cut or chew. Resident #12 confirmed she ate the cake and lettuce because it was easier to chew.Interviews 06/24/26 at 5:59 P.M. with Dietary Manager #158 and Regional Director of Clinical Service (RDCS) #211 confirmed Resident #12 had active orders for a mechanical soft diet. Dietary Manager #158 and RDCS #211 confirmed Resident #12 was given the wrong dinner tray.

Based on interviews with residents and staff, and record review, the facility failed to ensure arbitration agreements were properly and thoroughly explained to the residents. This affected one (Resident #24) of three residents reviewed for arbitration. The facility identified 36 residents who had active signed arbitration agreements. The facility census was 59. Findings include:Review of the medical record for Resident #24 revealed an admission date of 05/10/26. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating Resident #24 had intact cognition.Review of the Arbitration agreement signed 05/14/26 revealed Resident #24 marked accept to the arbitration agreement. Interview on 06/23/26 at 12:30 P.M. with Resident #24 reported she remembered signing the admission paperwork. The arbitration agreement was discussed and Resident #24 reported the arbitration information was not discussed in a clear manner and also reported the arbitration agreement meant she could appeal her discharge and change her mind. Interview on 06/24/26 at 10:30 A.M. with the Admissions Director (AD) #209 confirmed she provided the information to the residents to read and if they need assistance, she will read the form to them verbatim. AD #209 confirmed arbitration was a way for residents to settle disputes with the facility and the residents can rescind the agreement at anytime. AD #209 was unaware the agreement stated residents could only rescind within 30 days of signing the agreement and was unaware of its significance in a resident waiving their right to sue and go in front of a judge or jury for damages. AD #209 confirmed the facility provided little training regarding the arbitration agreement and reported she did an internet search to get an idea so she could explain it to residents.

Based on observations and staff and resident interviews, the facility failed to ensure the resident's doors could open and close easily. This affected two (#34 and #44) of five residents reviewed for physical environment. The facility census was 59. Findings include: 1. Review of the medical record for Resident #34 revealed an admission date of 05/08/23. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had intact cognition and was independent with most activities of daily living and mobility. Observation and interview on 06/22/26 at 12:35 P.M. with Resident #34 revealed the door sticks about mid-swing and was tight on the floor scraping and causing damage to the flooring. Resident #34 reported it had been in this condition for several weeks since she moved into the room and she was unsure of a plan to fix the door. Interview and observation on 06/24/26 at 8:00 A.M. with Maintenance Director #208 confirmed Resident #34's door was getting stuck midway and scuffing the floor. Maintenance Director #208 stated he was aware of a closet door that needed shaved down but was not aware of room doors were sticking or scuffing the floors for Resident #34. He reported the facility used a texting system for items that need fixed or repaired and did not have a ticket system and was unable to provide any evidence of maintenance requests. 2. Review of the medical record for Resident #44 revealed an admission date of 01/04/23. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had impaired cognition. Interview and observation on 06/24/26 at 8:02 A.M. with Maintenance Director #208 confirmed Resident #44's closet door was sticking to the ground when opening/closing it. Maintenance Director #208 revealed he was aware of a closet door that needed shaved down but was not aware of doors that were sticking for Resident #44. Maintenance Director #208 reported the facility used a texting system for items that need fixed or repaired and did not have a ticket system and was unable to provide any evidence of maintenance requests.

Based on medical record review, staff interviews, policy review, and review of manufacturer instructions, the facility failed to ensure adequate supervision and assistance were provided to the residents to prevent falls and failed to complete thorough investigations into the resident's falls. This affected two (Residents #54 and #61) of four residents reviewed for accidents. The facility census was 59.Findings include:1. Review of Resident #61's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus, general anxiety disorder, and muscle weakness.Review of the physician orders dated 09/19/24 revealed Resident #61 was admitted to hospice with a primary diagnosis of cerebral atherosclerosis. Resident #61 was in the terminal stage of illness and required intensive monitoring and care coordination.Review of the care plan dated 09/24/24 and last revised on 05/12/26 revealed Resident #61 was a low risk for falls related to gait/balance problems with an actual fall on 05/05/26 during care. Interventions included following facility fall protocol. Resident #61 required staff intervention to complete self-care and mobility activities and the resident was at risk for decline in functional ability and usual performance associated with complications. Resident #61's care plan did not have any safety interventions related to care with use of an air mattress.The Fall Risk Evaluation dated 01/24/26 identified Resident #61 was at a high risk for falls.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had severe cognitive deficits. Resident #61 was totally dependent on staff for transfers and bathing and was dependent on staff with all other activities of daily living (ADL) including rolling left and right, sitting to lying, and lying to sitting transfers. The progress note dated 05/05/26 at 6:00 P.M. revealed Resident #61 experienced a fall during wound care that shift. While Licensed Practical Nurse (LPN) #141 was obtaining supplies from the bedside table, Resident #61 reached and shifted position, resulting in rolling off the bed. LPN #141 attempted to intervene and prevent the fall but was unsuccessful. Resident #61 contacted the floor and struck her head. A small open area noted to the head with active bleeding measuring one centimeter (cm) in length with no width measurement. Bleeding was controlled with pressure and the site was cleansed. Emergency Medical Services (EMS) was called at this time.Review of the hospital records dated 05/05/26 and 05/06/26 revealed Resident #61 presented with a fall and head injury. Resident #61 rolled out of bed, hitting her head, and sustaining an abrasion to the forehead. Resident #61 sustained a left frontal contusion and abrasion. Resident #61 was alert and oriented at baseline mental status. Review of the medical record revealed there was no fall investigation for Resident #61's fall on 05/05/26. The facility did not provide any investigation into Resident #61's fall on 05/05/26.During an interview on 06/24/26 at 9:14 A.M., LPN #141 revealed she was performing wound care on Resident #61 on 05/05/26. LPN #141 stated she was rolling Resident #61 during wound care. The air mattress was in use, but the mattress was not placed in static mode prior to the care activity. LPN #141 documented the air mattress almost threw the resident during the rolling motion and the air pushing the resident off the bed. Resident #61 struck her forehead. LPN #141 confirmed when Resident #61 fell, the resident was positioned on her stomach, and the resident was too heavy to roll back over independently. LPN #141 stated Resident #61 was a two-person assist whenever she was in the room and confirmed she was actively handling Resident #61 during the rolling for wound care. During an interview on 06/25/26 at 11:33 A.M., Registered Nurse (RN) #350 confirmed the air mattress provided by hospice had a firm or static mode setting or a maximum inflate button to make the mattress firmer for repositioning, wound care, or incontinence care. RN #350 also confirmed proper safety measures during resident transfers included ensuring the resident was positioned in the middle of the bed prior to care and utilizing two staff members to ensure safety during all transfers.During an interview on 06/25/26 at 1:56 P.M., the Director of Nursing (DON) and Regional Clinical Nurse #211 confirmed the facility did not complete a fall investigation and obtain witness statements and determine the root cause of Resident #61's fall on 05/05/26. The DON stated the fall investigation would be in the resident's electronic medical record. Regional Clinical Nurse #211 stated the facility was actively addressing fall management through its Quality Assurance and Performance Improvement (QAPI) program.Review of the Advacare Guidelines for air mattress systems revealed the mattress has a static mode setting that provided a firm surface to make it easier for the patient to transfer or reposition. The static button should be pressed to set the mattress in static mode.2. Review of the medical record for Resident #54 revealed a re-admission date of 11/06/24. Diagnoses included fracture of the upper end of the right humerus with routine healing, chronic obstructive pulmonary disease, generalized anxiety disorder, and mood disorder.Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/18/25, revealed Resident #54 was cognitively intact. Resident #54 was independent with activities of daily living including bed mobility, transfers, ambulation, dressing, toileting, and personal hygiene. Resident #54 had no falls.Review of the nursing documentation dated 02/13/26 revealed Resident #54 experienced a witnessed fall while walking outside the facility toward the transport bus for a scheduled appointment. Resident #54 stated, I fell over my foot. The physician was notified, Emergency Medical Services (EMS) was contacted, and the resident was transported to the hospital. Nursing documented the resident would receive a therapy evaluation for ambulation and gait upon return to the facility. A subsequent nursing note documented the fall was witnessed and the resident did not strike his head.Review of the medical record revealed there was no fall investigation for Resident #54's fall on 02/13/26. The facility did not provide any investigation including any staff statements into Resident #54's fall on 05/05/26. There was no root cause of Resident #54's fall.Review of the hospital records dated 02/13/26 through 02/15/26 revealed Resident #54 was evaluated following the fall and reported pain and rated the pain eight out of ten (from a pain scale ranging from zero (no pain) to ten (most severe pain)). Diagnostic imaging identified an acute comminuted fracture involving the surgical neck of the proximal right humerus with anterior displacement of the diaphysis in relation to the humeral head. A sling was applied, pain management was initiated, and no surgical intervention was recommended. Review of the post fall documentation dated 02/15/26 revealed Resident #54 experienced another unwitnessed fall after returning to the facility against medical advice from the hospital. Resident #54 was found sitting beside the bed and stated, I fell down. The post fall investigation identified the reason for the fall as Resident #54 just left the hospital without being discharged , returned to facility on 7:00 A.M. to 7:00 P.M. shift The investigation did not identify an actual cause of the fall or evaluate factors contributing to the event. The only intervention implemented was education, instructing Resident #54 to use call light when assistance was needed.The facility was unable to provide an investigation including any witness statements regarding Resident #54's fall on 02/15/26.Review of the physician orders dated 02/16/26 revealed orders for the resident to remain non-weight bearing to the right arm, perform circulation checks to the radial and brachial pulses every shift, and report abnormalities following the right humerus fracture.The nursing documentation dated 02/16/26 revealed hospital staff informed the facility Resident #54 had left the hospital against medical advice due to smoking in his hospital room. Nursing documented Resident #54 had a right humerus fracture with anterior displacement, required no surgical intervention, was to remain in a sling, remain non-weight bearing, and follow up with Orthopedics.Review of the plan of care, revised 02/17/26, revealed Resident #54 was at risk for falls related to gait and balance problems and a previous fall with fracture. Interventions included ensuring the call light remained within reach, educating the resident to request assistance when needed, ensuring appropriate footwear when ambulating, following the facility fall protocol, maintaining non-weight bearing status to the right arm with a sling as tolerated, therapy evaluation and treatment, educating the resident to pick up his feet while ambulating, and positioning the right side of the bed against the wall to enhance floor space. Review of the post fall documentation dated 05/24/26 revealed Resident #54 experienced an unwitnessed fall at approximately 2:00 A.M. while sleeping. Resident #54 rolled from the bed after continuing to sleep near the edge of the bed despite being instructed several times not to do this because he was at a high risk for falls. Resident #54 sustained a skin tear to the left elbow. The documentation revealed the bed height was appropriate, and the resident was using his prescribed assistive device. The corresponding nursing note documented the resident was found lying on his back with a skin tear to the left elbow, denied striking his head, and was assisted back to bed.Interview with the Director of Nursing (DON) on 06/25/26 at 10:32 A.M. revealed the reason documented for the 02/15/26 fall investigation was not a valid explanation for the fall. The Director of Nursing stated all three falls required further review.Interview with the DON and Regional Clinical Nurse #211 on 06/25/26 at 1:56 P.M. revealed the post fall assessments should have been completed in their entirety. They confirmed the fall investigations were incomplete, and the interventions implemented following the falls were not appropriate. Regional Clinical Nurse #211 stated the facility was actively addressing fall management through its Quality Assurance and Performance Improvement (QAPI) program.Review of the facilities policy titled Accidents and Supervision, dated in 2025, revealed the facility is required to provide adequate supervision and assistive devices based on individual resident assessed needs and ensure staff are trained and monitored to consistently implement interventions. There are systematic approaches the facility should take: identification of hazards and risks, evaluation and analysis the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents, implementation of interventions, monitoring and modification for care plans, and supervision to prevent further falls. This deficiency represents non-compliance investigated under Complaint Number 3022603.

Based on record review, staff interview, hospice interview, the failed to provide joint collaborative effort and ongoing hospice communication when Resident #61 exhibited a change in condition. This affected one (Resident #61) of two residents reviewed for death. The facility census was 59. Findings include: Review of the medical record for Resident #61 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included cerebral atherosclerosis The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had moderate cognitive impairment. Review of the physician orders revealed Resident #61 was admitted to Hospice with a hospice diagnosis of cerebral atherosclerosis. Review of the nursing documentation dated [DATE] at 5:00 A.M. revealed Resident #61's treatment was completed as physician ordered. Resident #61 continued with a rattle to chest, and denies pain or discomfort. There was no documentation that hospice, the physician, or the resident's representative were notified of the newly documented rattling in the chest. The nursing documentation dated [DATE] at 6:00 A.M. revealed the nurse entered the room and found Resident #61 without signs of life. Hospice was then contacted after the resident was found deceased .Review of the hospice documentation revealed Resident #61 was pronounced deceased at 6:00 A.M. on [DATE].Interview with Hospice Registered Nurse (RN) #350 on [DATE] at 11:03 A.M. revealed hospice visited with Resident #61 on [DATE] and did not visit him until hospice was notified he was deceased . RN #350 stated hospice would expect a call from the facility for any significant change in condition, including new rattling in the chest, because hospice could have evaluated the resident and potentially initiated medications to help manage the rattling.Interview with the Director of Nursing (DON) on [DATE] at 10:24 A.M. revealed when a resident develops rattling in the chest, staff should increase monitoring to at least hourly checks and notify the physician, hospice, and the Power of Attorney. The DON confirmed the medical record did not show those notifications occurred and did not show increased monitoring or additional vital sign checks after the rattling was documented.Interview with Medical Director (MD) #400 on [DATE] at 11:33 A.M. revealed he was not informed of the rattling in the chest and stated he would expect to be notified if the rattling was persistent or represented a change in condition.This deficiency represents non-compliance investigated under Complaint Numbers 3022603 and 2965086.

Based on observation, resident and staff interviews, and medical record review, the facility failed to honor a resident's preferences for bathing. This affected one (Resident #77) of three residents reviewed for preferences. The facility census was 59.Findings include:Review of Resident #77's medical record revealed the resident had an admission date of 6/03/26. Diagnoses include acute and chronic respiratory failure, chronic diastolic failure, cerebral infarction, and weakness. The Minimum Data Set (MDS) assessment last revised on 6/10/26 revealed Resident #77 did not have any memory issues and required substantial/maximal assistance from staff with bathing and showering.Review of Resident #77's preferences dated 6/03/26 revealed the resident preferred to have showers.Review of the care plan last revised 06/04/26 revealed Resident #77 was at risk for decline in actives of daily living (ADL) related to a fall at home. Interventions include allow time for rest breaks and encourage the resident to participate in ADLs.Review of the shower log revealed Resident #77 received a bed bath on 06/11/26, 06/15/26, and 06/18/26 Interview on 06/23/26 at 7:54 A.M. with Resident #77 revealed the resident was receiving bed baths and preferred to have showers. Resident #77 stated he was not aware if the facility would be able to assist him with showers due to his recent stroke.Interview on 06/25/26 at 12:53 P.M. with the Regional Director of Nursing (RDON) #211 confirmed Resident #77 had received bed baths and not their preferred showers on 06/11/26, 06/15/26, and 06/18/26. RDON #211 confirmed Resident #77's preferences will be honored and the resident was given a shower on 06/25/26.This deficiency represents non-compliance investigated under Complaint Numbers 3011478 and 2661156.

Based on record review, staff interview, and policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) assessment was accurately completed for Resident #10. This affected one (#10) of one resident reviewed for PASARR. The facility census was 59. Findings include: Review of the medical record for Resident #10 revealed an admission date of 04/17/26. Diagnoses included schizophrenia and anxiety. Review of the PASARR assessment dated [DATE] revealed Resident #10 was marked no regarding having no mental disorders Interview on 06/23/26 at 4:35 P.M. with Social Services Director (SSD) #194 confirmed Resident #10's PASARR assessment documented that Resident #10 did not have a mental health diagnosis. SSD #194 confirmed the medical record indicated Resident #10 had diagnosis of anxiety and schizophrenia and was being treated for both. SSD #194 confirmed he completed it incorrectly and stated he would need to correct it and it may trigger for a level two assessment. Review of the facility policy titled PASARR Statuses undated revealed the facility was required to complete a pre-admission screening related to mentally ill individuals within 30 days of admission and upon a change in diagnosis.

Based on record reviews, staff interview, and policy review, the facility failed to ensure care plans accurately reflected the resident's medical conditions and failed to ensure the care plan was fully completed. This affected one (Resident #12) of four residents reviewed for care plan accuracy. The facility census was 59.Findings include:Review of the medical record for Resident #12 revealed an admission date of 03/26/26. Diagnoses included late onset Alzheimer's disease, type two diabetes mellitus, schizoaffective disorder, anxiety, and major depressive disorder.Review of the admission Minimum Data Set (MDS) 3.0 assessment 04/02/26 revealed Resident #12 had short and long term memory impairment and severely impaired decision-making. Resident #12 required supervision or light assistance with showering, toileting, and dressing herself. Resident #12 had active diagnoses which included anxiety disorder, depression, diabetes mellitus, and schizophrenia.Review of Resident #12's care plan revealed focus areas which included Resident #12's use of antianxiety medications to manage anxiety, antidepressant medications to manage depression, and antipsychotic medications for the management of behaviors related to dementia. There were no other goals or interventions in the care plan regarding symptom monitoring, management, or interventions for anxiety, depression, diabetes, and schizophrenia. Resident #12's care plan had incomplete goals and interventions which included check tubing for kinks [# TIMES] each shift, the resident will participate in care by performing (SPECIFY) through next review date, and educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of (SPECIFY: antidepressant drugs being given).Interview on 06/25/26 at 3:30 P.M. with Regional Director of Clinical Services (RDCS) #211 confirmed Resident #12's care plan did not include goals and interventions for monitoring and managing her health conditions. RCDS #211 confirmed Resident #12's care plan had goals and intervention templates that were incomplete.Review of the policy titled Comprehensive Person-Centered Care Plans, revised 03/2022, revealed the comprehensive person-centered care plan describes services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on resident and interviews, medical record review, and policy review, the facility failed to ensure appropriate follow-up was completed to obtain the hearing assistive device recommended for a resident. This affected one (#20) of one resident reviewed for assisted devices. The facility census was 59. Findings include:Review of the medical record for Resident #20 revealed a re-admission date of 08/12/25. Diagnoses included chronic obstructive pulmonary disease, insomnia, and chronic pain.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had intact cognition. Resident #20 had adequate ability to hear with hearing aids or hearing appliances if normally used, had clear speech, was able to make himself understood, and did not currently have hearing aids.Review of the resident's care plan did not reveal interventions addressing hearing impairment, hearing aid recommendations, or follow-up related to obtaining hearing aids.Review of an Audiology 360 Care consultation dated 01/20/26 revealed Resident #20 underwent a hearing evaluation. Documentation identified the resident was interested in a hearing aid trial. The audiologist recommended a new Resound monaural receiver-in-canal hearing aid for the left ear. The consultation further stated hearing aids would not be ordered until a signed physician clearance was obtained and a payor source or purchase order had been secured.There was no documentation the facility obtained physician clearance, secured a payor source, scheduled follow-up services, or otherwise acted upon the audiologist's recommendation after 01/20/26.Interview with Resident #20 on 06/22/26 at 11:15 A.M. revealed he requested hearing aids in July 2025 and stated he had needed hearing aids since his admission to the facility. The resident stated he had not heard from anyone regarding obtaining hearing aids.Interview with Social Service Director (SSD) #194 on 06/23/26 at 1:42 P.M. revealed he did not recall seeing the Audiology 360 Care recommendation for a hearing aid trial. SSD #194 confirmed Resident #20 had not followed up with him regarding hearing aids. SSD #194 confirmed the Audiology 360 Care recommendation for a hearing aid trial had been entered into the electronic medical record and was available for facility staff to review. SSD #194 stated he would follow up with the scheduler and other staff to determine whether any appointment or additional follow-up had occurred.Interview with SSD #194 on 06/24/26 at 2:16 P.M. revealed he had not discussed the hearing aid recommendation with anyone at that time. Review of the facility policy titled Hearing Impaired Resident, Care of, revised February 2018, revealed staff were responsible for assisting hearing-impaired residents in maintaining effective communication with clinicians, caregivers, other residents, and visitors. Staff are to assist residents or their representatives with locating available resources, scheduling appointments, arranging transportation to obtain needed hearing services, assisting with care and maintenance of hearing devices, replacing lost or damaged hearing devices, evaluating residents' adaptive needs at regular intervals, and addressing avoidable barriers to effective communication.

Based on resident and staff interviews, record review, and policy review, the facility failed to have a complete policy to address when it was the facilities responsibility to replace lost or missing dentures. This affected one (Resident #36) of three residents reviewed for dental services. The facility census was 59.Findings include:Review of Resident #36's medical record revealed an admission date of 06/07/24. Diagnoses included paraplegia, psychoactive substance abuse, major depressive disorder, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had intact cognition. Review of the care plan dated 03/05/25 revealed Resident #36 had oral and dental health problems to rule out injury, poor nutrition, and poor oral hygiene. The care plan did not address that Resident #36 had dentures and did not have interventions for cleaning the dentures and safe place for storage of the dentures.Interview on 06/24/26 at 11:47 A.M. with Resident #36 revealed on or around the evening of 05/23/26, staff removed their upper dentures and placed them on their bedside table before falling asleep. While Resident #36 was resting, an unknown staff member entered their room and cleaned their room and when they awoke, they discovered their upper dentures were missing. Resident #36 notified the Administrator of the missing upper dentures and after an extensive search, the facility was unable to locate the missing upper dentures. The facility reached out to the dental office and a replacement was quoted at approximately $1,400. Resident #36 confirmed they did not have their upper dentures due to a dispute with the facility regarding who would be responsible for the cost of the dentures.Interviews on 06/24/26 at 4:11 P.M. with the Administrator confirmed Resident #36 had reported their upper dentures missing to the facility and staff had searched the resident's room and were unable to locate the upper dentures. Afterwards, the facility reached out to the dental office and the missing upper dentures were quoted at $1,500 dollars. After investigating, the facility had concluded that neither the resident nor the facility could be found at fault and had told the resident to pay half of the cost of the dentures. On 06/29/26 at 3:13 P.M. confirmed the Administrator confirmed the facility's policy titled Dental Services did not specify the facility's protocol for lost or broken dentures when it is the facilities responsibility.Review of the undated facility policy titled Dental Services revealed the facility will identify those instances when the loss or damage of partial or full dentures is the facilities responsibility, such as when a staff member discards dentures on a meal tray. Under D of the policy, it stated to Insert facility specific protocol for lost or broken dentures here. However, the facility had not inserted their specific protocol for lost or broken dentures.This deficiency represents non-compliance investigated under Complaint Number 3022265.

Based on record review, resident and staff interviews, and policy review, the facility failed to ensure quarterly care conferences were offered/completed for Resident #34 and failed to ensure Resident #12's care plan was updated timely. This affected one (Resident #34) of three residents reviewed for care plan conferences and one (Resident #12) of 24 residents reviewed for care plan revisions. The facility census was 59.Findings include: 1. Review of the medical record for Resident #34 revealed an admission date of 05/08/23. Diagnoses included anxiety, insomnia, diabetes mellitus, chronic pulmonary disease, and heart failure. Review of the care conference documentation revealed care conferences were held on 06/30/25, 11/30/25, 01/22/26 and 04/22/26. The record review found no evidence of care conference being held for five months until 11/30/25. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had intact cognition and was independent with most activities of daily living and mobility. Interview on 06/22/26 at 12:35 P.M. with Resident #34 reported facility had not held care conference on a quarterly basis. Interview on 06/23/26 at 1:38 P.M. with Regional Director of Clinical Services #211 stated the facility was cited for care conferences on the last annual and they completed an audit and training to ensure compliance. Interview on 06/23/26 at 4:40 P.M. with Social Service Director #194 and Regional Director of Clinical Services #211 confirmed the facility was missing a care conference for Resident #34 from 07/2025 to 10/2025. Review of facility policy titled IDT (Interdisciplinary) Team Members Participation in Resident Care Conferences dated 03/2023 revealed the IDT team shall ensure each resident had consistent and routine care conferences. 2. Review of the medical record for Resident #12 revealed an admission date of 03/26/26. Diagnoses included late onset Alzheimer's disease, schizoaffective disorder, anxiety, and major depressive disorder. Review of the progress note dated 05/08/26 revealed Resident #12 was referred to psychiatric services on 05/08/26. Resident #12 was first seen by psychiatric services on 05/19/26. Review of Resident #12's care plan revealed no goals or interventions were in the care plan regarding symptom monitoring, management, or interventions for anxiety, depression, and schizophrenia. There were no interviews for side effect monitoring for antianxiety, antidepressant, and antipsychotic medications. The nursing progress notes revealed on 06/11/26 at 11:48 A.M., poison control was called because Resident #12 had ingested a foreign material. At 1:04 P.M., Resident #12 informed housekeeping staff that she wanted to die, planned to drink chemicals to make her die, and she had ingested body wash. Resident #12's physician and psychiatric nurse practitioner were called, and Resident #12 was pink-slipped (emergency involuntary psychiatric 72-hour hold) and taken to the emergency for further evaluation and treatment. Resident #12's care plan was last revised on 04/17/26 and did not include Resident #12's suicidal ideation. Interview on 06/25/26 at 11:57 A.M. with Social Services Designee (SSD) #194 confirmed Resident #12's care plan was not updated following suicidal ideation and involuntary psychiatric hold. Interview on 06/25/26 at 3:30 P.M. with Regional Director of Clinical Services (RDCS) #211 confirmed Resident #12's care plan should have been updated following suicidal ideation and involuntary psychiatric hold. This deficiency represents non-compliance investigated under Complaint Numbers 2661156 and 2965086.

Based on record review and staff and resident interviews, the facility failed to ensure detailed documentation of accounting practices were in place for four (Residents #9, #26, #34, and #38) of five active resident accounts reviewed. The facility census was 59. Findings include: 1. Review of the personal fund statement dated 10/01/25 to 06/03/26 revealed she received credits of $50 and $75 and each of these credits were listed as cash receipts. Interview on 06/22/26 at 12:35 P.M. with Resident #34 revealed she had concerns related to access to money and knowing about the money in her account. 2. Review of Resident #9's personal fund statement dated 10/01/25 to 06/03/26 revealed he received credits of $50 and $75 each of these credits were listed as cash receipts. 3. Review of Resident #26's personal fund statement dated 10/01/25 to 06/24/26 revealed he received credits of $50 and $75 each of these credits were listed as cash receipts. 4. Review of Resident #38's personal fund statement dated 10/01/25 to 06/03/26 revealed he received credits of $50 and $75 each of these credits were listed as cash receipts. Interview on 06/24/26 at 4:00 P.M. with Business Office Manager (BOM) #136 confirmed Resident #34, #9, #26, and #38 had deposits made into their personal funds account and labeled them as cash receipts. BOM #136 explained there were deposits into their accounts from their monthly allowance from social security/income. BOM #136 stated she was not aware all deposits should specify what they were.

Based on an observation, staff and resident interviews, medical record review, diet tech audit review, and policy review, the facility failed to ensure food had a palatable taste and was served at an appetizing temperature. This affected four (#1, #16, #30, and #367) of six residents reviewed for dietary needs. The facility identified all residents eat food from the kitchen. The facility census was 65. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 08/13/24. Diagnoses included pneumonia, malnutrition, hemiplegia, heart failure, vascular disease, and respiratory failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had moderate cognitive impairment with a Brief Interview Mental Status (BIMS) of 11. Interview on 04/29/25 at 4:32 P.M. with Resident #7 revealed food wasn't good and didn't have good taste. 2. Review of the medical record for Resident #367 revealed an admission date of 03/11/25. Diagnoses included chronic obstructive pulmonary disease, depression, atrial fibrillation, and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #367 was cognitively intact with a Brief Interview Mental Status (BIMS) of 15. Interview on 04/28/25 at 3:16 P.M., with Resident #367 revealed food was not good and was cold. 3. Review of the medical record for Resident #1 revealed an admission date of 09/06/18. Diagnoses included atrial fibrillation, diabetes, heart disease and dysphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact with a Brief Interview Mental Status (BIMS) of 15. Interview on 04/28/25 at 10:25 A.M., with Resident #1 revealed food that was served was not hot. Review of facility diet tech audit dated 03/25/25 revealed puree food looked pasty, lacked flavor and appearance, standard recipes (including puree recipe) not being followed. Review of facility diet tech audit dated 04/29/25 revealed nutrition recommendations were not addressed from the previous visit. Food was not cooked in a way to conserve nutritive value, flavor and appearance. Upon diet tech test tray it was determined the food was very salty and unappealing, food was cold and below an acceptable range. 4. Review of Resident #16's medical record revealed an admissions date of 02/07/25. Diagnoses include coronary artery disease, hypertension, diabetes mellitus, seizures, anxiety, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 is cognitively intact. Interview with Resident #16 on 04/28/25 at 3:09 P.M. revealed the food being served does not taste good. Resident #16 stated that the food is not served warm enough and is often cold. Observation on 04/29/25 at 11:55 A.M., with Dietary [NAME] #214 revealed prior to the start of tray line, the cream of rice had a temperature of 140 degrees, the pureed [NAME] chicken had a temperature of 135 degrees, the pureed vegetables had a temperature of 148 degrees and the regular [NAME] chicken had a temperature of 176 degrees. Observation on 04/29/25 at 12:41 P.M., with Dietary [NAME] #214 revealed when plating the test tray, the cream of rice had a temperature of 137 degrees, the pureed vegetables had a temperature of 118 degrees and the regular [NAME] chicken had a temperature of 155 degrees. When asked about what temperature staff was looking for the tray line items, Dietary [NAME] #214 revealed 165-175 degrees. The test tray left the kitchen at 12:47 P.M. Observation and interview on 04/29/25 at 1:06 P.M., with Kitchen Manager #237 revealed the cream of rice had a temperature of 94 degrees, the pureed vegetables had a temperature of 91 degrees and the regular [NAME] chicken had a temperature of 92 degrees. Kitchen Manager #237 along with survey team tried the items and confirmed they tasted cold and the [NAME] chicken tasted very salty. Kitchen Manager #237 also revealed the cream of rice tasted bland. Kitchen Manager #237 revealed facility had metal warming dish to keep plates warm and don't use them but stated we could start using them. Observation and interview on 04/29/25 at 3:10 P.M., with Diet Tech #506 revealed she typically with do a test tray and audits about monthly and revealed the last two audits she completed found facility palatability concerns with taste and temperature. She revealed food should be served over 120 degrees and reported she also tried the meals this date and found the items to be cold and the meat to be salty. She revealed she also spoke with residents in the dining room who also confirmed the food was cold and the meat was salty. Review of the policy titled, Palatability and Nutritive Value, dated 06/27/23 revealed food shall be prepared, held and served in a manner that preserves nutritive value and palatability. Hot foods would be held at 135 degrees. The facility shall make best efforts to present hot foods hot at point of service by using thermal lids and bases and thermal pellets as needed. Food service staff shall monitor palatability of food at point of service by periodic test tray evaluation. This deficiency represents the noncompliance investigated under Complaint Number OH00164520.

Based on observations, staff and resident interviews, medical record record review, meals substitute log review, menu review, diet tech audit review, and policy review, the facility failed to follow meal tickets and scheduled menu and an updated/ accurate substitution log. This affected two (#16 and #30) of three residents reviewed for nutrition with potential to affect all residents who receive meals from the dining room. Facility identified all facility residents eat food from the kitchen. The facility census was 65. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 08/13/24. Diagnoses included pneumonia, malnutrition, hemiplegia, heart failure, vascular disease, and respiratory failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had moderate cognitive impairment with a Brief Interview Mental Status (BIMS) of 11. Interview and observation on 04/28/25 at 12:34 P.M. with Resident #30 revealed the food that was served did not match the meal ticket. Resident #30's food ticket was dated 04/27/24, Sunday lunch and stated resident had a mechanical diet. It also stated resident should receive broccoli and potato soup, basked ziti with four cheese, shredded lettuce, and applesauce. Resident #7 only had a cup of vegetable soup and a small ice cream cup on her tray. Resident #30 reported what she gets served never matches the ticket or the menu. Resident #30 stated she was still hungry and would like more to eat than just a cup of soup. Interview and observation on 04/28/25 at 12:35 P.M., with Certified Nurse Aide #282 confirmed residents tray items did not match the ticket and confirmed the kitchen did not typically follow the posted menu and they heard regular complaints from residents about the items not matching the tickets on the tray. 2. Review of Resident #16's medical record revealed an admissions date of 02/07/25. Diagnoses include coronary artery disease, hypertension, diabetes mellitus, seizures, anxiety, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 is cognitively intact. Interview with Resident #16 on 04/28/25 at 3:09 P.M., revealed she does not receive a menu for each meal. Resident #16 stated that she doesn't know what she will be getting for each meal. Observation of the lunch served on 04/28/25 at approximately 12:30 P.M., revealed that chicken salad sandwiches were being served instead of the meat loaf that was listed on the scheduled menu for the day. Interview dated 04/29/25 at 12:53 P.M., with Kitchen Manager (KM) #237 confirmed the resident meals do not always match what was on the menu. KM #237 revealed the facility was unable to find the complete substitution log. Review of substitution log dated April 2025 revealed the 04/28/25 change in the lunch meal was not included on the substitution log. It mentioned dinner meal it added chicken salad in place of salad but included no mention of switching the meat loaf and the mashed potatoes and gravy and the fruit cup. Observation and interview on 04/29/25 at 3:10 P.M., with Diet Tech #506 revealed she typically would do a test tray and audits about monthly and revealed in recent audits she completed found facility did not follow the menu or spreadsheets. She also revealed when she had requested the substitution logs for the last two months, facility was unable to supply any evidence of the substitution log. Review of facility diet tech audit dated 03/25/25 revealed standard recipes (including puree recipe) was not being followed, and substitution log was not found. Review of facility diet tech audit dated 04/29/25 revealed nutrition recommendations were not addressed from the previous visit. Menu with spreadsheets were not followed, and substitution log was not found. Review of the menu for 04/28/25 revealed the lunch meal included homemade meatloaf, mashed potatoes and gravy, bread, peas and carrots, and mixed fruit. Review of facility policy titled, Menus, dated 04/25/24 revealed menus should be prepared in advance. Menus should be approved by the dietician if the meal changes for any reason from the planned menu, the reason for the change should be documented and maintained in the kitchen. This deficiency represents the noncompliance investigated under Complaint Number OH00164520.

Based on observation, staff interviews and policy review, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect all 65 residents. The facility census was 65. Findings include: Observation of the walk in freezer on 04/28/25 at 8:49 A.M. revealed frozen waffles in a bag without a date. Ice was observed on the tops of boxes of Mighty Shakes and B/C Topping that were stored under the freezer condenser. Interview with the Kitchen Manger (KM) #237 confirmed that the frozen waffles did not have a date. KM #237 confirmed that the condenser appeared to be leaking and creating a build up of ice on the boxes stored below. Observation on 04/28/25 at 8:54 A.M. revealed Dietary Aide (DA) #284 testing the chemical dish machine with a chlorine test strip that appeared to be a light purple. Interview with DA #284 verified that the test strip showed that the chlorine concentration in the dish machine was at 25 parts per million (PPM). DA #284 verified that the dish machine should have a concentration of 50-100 PPM of chlorine. Observation of the refrigerator on 04/28/25 at 8:55 A.M. revealed an open bottle of ketchup dated 04/19/25, 26 containers of thickened cranberry cocktail with an expiration date of 04/18/25, 15 containers of thickened lemonade with an expiration date of 02/05/25, an open package of slice turkey without a date and a carton of B/C topping without a date. Interview with DD #237 confirmed that the ketchup, cranberry cocktail, lemonade were past their expirations date. KM #237 confirmed that the sliced turkey and B/C topping were not dated. Observation of the dry stock on 04/28/25 at 9:08 A.M. revealed a container of flour without a date marked, a container of egg noodles without a date marked, and a box of care thickened hot cocoa mix with an expiration date of 03/01/25. Interview with KM #237 confirmed that both containers did not have a date marked and that the cocoa mix was past the expiration date. Observation in the kitchen on 04/28/25 at 9:14 A.M. revealed an open bag of hot dog buns without a date marked. Interview with KM #237 confirmed that the hot dog buns did not have a date on the bag. Observation of the preparation of the pureed lunch menu on 04/29/25 at 11:18 A.M. revealed Dietary [NAME] (DC) #214 pour the pureed [NAME] chicken into a metal pan that had a yellow residue inside. Interview DC #214 confirmed that there was a residue in the metal pan and that she believed that it was a residue from chicken base. DC#214 confirmed that she grabbed the pan from the stack of clean pans that were stored under the preparation table. Observation of the dry stock on 04/29/25 at 11:38 A.M. revealed an open bags of spaghetti noodles, navy beans and white rice without a date marking when they were opened. Interview with KM #237 verified that the bags were not marked with an opened date. Observation of the walk in cooler on 04/29/25 at 11:39 A.M. revealed raw hamburger meat being stored above gallons of milk and bags of cheese. Interview with KM #237 confirmed that the raw meat was stored above ready to eat food. Further observation of the lunch service on 04/29/25 at 12:10 P.M. revealed KM #237 enter the kitchen with a metal pot and filled the pot with water at the prep sink. KM #237 then placed several hot dogs into the pot and placed in on the stove. A residue was then observed on the outside of the pot. Interview with KM #237 verified that the pot was dirty. Observation on 04/29/25 at 12:27 A.M. revealed DC #214 scoop a serving of white rice on top of a green residue that was on the plate. DC #214 scraped the rice into the trash to reveal that a green residue was on the plate. DC #214 confirmed that the plate was dirty. Observation of the dish machine on 04/29/25 at 1:25 P.M. revealed that the water temperature gage was at 115 degrees Fahrenheit for the entire cycle. KM #237 tested the chlorine sanitizer in the dish machine and the test strip appeared to be a light purple. Interview with KM #237 verified that the water temperature gage seemed to be stuck at 115 degrees Fahrenheit and the concentration of the chlorine was at 25 PPM. Observation of lunch service on 04/29/25 at 12:14 P.M., revealed Dietary Aide (DA) #284 lift the lid of the trash can to throw away disposable gloves. DA #284 then began assembling items for the lunch trays, including handling silverware, cups and plates without washing her hands. Interview with DA #284 on 04/29/25 at 12:18 P.M., confirmed that she did throw away a pair of disposable gloves and then touch clean kitchen utensils without washing her hands in between. When DA #284 was asked when staff should be washing their hands, she stated that hands should be washed as needed. Interview with the Kitchen Manger #237 #237 on 04/29/25 at 12:19 P.M. confirmed that staff should be washing their hands after touching the lid of the trash can. Review of the undated policy titled Hand Washing revealed hands and exposed portions of arms should be washed after handling soiled equipment or utensils. Review of the undated policy titled, Low Temperature Door Machine revealed that sanitization solution should be tested three times a day and be 50-100 PPM. Further review of the policy revealed that the dish machine water temperatures should be between 120-140 degrees Fahrenheit. Review of the undated policy titled Food Storage revealed containers for bulk items (flour, sugar, etc.) are to be stored and sealed in a leak proof container with a date and label.

Based on medical record review, observation, resident and staff interview, and review of information from National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement preventative pressure ulcer interventions for a resident who was admitted with a pressure ulcer to the heel and failed to complete an ongoing assessment including staging of a pressure ulcer. This resulted in Actual Harm when staff failed to implement pressure ulcer preventative interventions for Resident #55 who was at risk for pressure ulcer development, was admitted with mushy heels (pressure ulcer) and subsequently the resident developed an unstageable pressure ulcer to the right heel. This affected one (#55) out of two reviewed for pressure ulcers. Facility census was 79. Findings include: Review of Resident #55's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of a facility document titled Admission Data Collection Form dated 07/08/19 revealed Resident #55 had mushy heels. Review of a facility document titled Pressure Ulcer Risk Data Form dated 07/08/19 revealed a score of 10 or more indicated the resident would be at risk for pressure ulcer development. Resident #55's total score was a seven. Further review of the assessment indicated a score of zero for the presence of a pressure ulcer and the score should have been an additional 10 points due to the presence of a pressure ulcer upon admission making the total score a 17 or at risk. Review of Resident #55's care plan revealed a care plan dated as initiated 07/10/19 for stage one pressure ulcers to bilateral heel and a care plan dated as initiated 09/28/19 for an unstageable pressure ulcer to right heel. Review of interventions listed revealed no interventions related to offloading of heels for either date. Review of a comprehensive admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #55 was admitted with two stage one pressure ulcers, required extensive assistance of one staff for walking and bed mobility, required extensive assist of one person for bed mobility and was at risk for pressure ulcer development. Review of a quarterly MDS dated [DATE] revealed Resident #55 had one pressure ulcer that was unstageable due to slough. Further review revealed Resident #55 was cognitively intact. Review of treatment administration records (TAR's) which contained skin assessment documentation from 07/16/19 through 10/10/19 revealed the following. on 07/16/19, 07/23/19, 08/05/19, 08/12/19, and 08/19/19 Resident #55 was documented as having no pressure areas. On 08/26/19 Resident #55 was documented as having a 0.5 centimeter (cm) by (x) 0.7 cm x zero cm and 1.5 cm x 0.5 cm x zero cm non-blanchable tan areas to his right heel. Then on 09/05/19, 09/10/19, and 09/17/19 Resident #55 again was documented as having no pressure areas on 09/03/19, 09/10/19, and 09/17/19. On 09/28/19 a reddish purple soft area measuring 5.0 cm x 3.0 cm was documented to Resident #55's right heel. On 10/07/19 Resident #55's right heel was documented as having a 4.0 cm x 4.5 cm black center surrounded with red bloody tissue peri-wound maceration. Review of TAR's from 10/12/19 through 01/20/20 revealed the following: on 10/15/19 Resident #55 was documented as having a 5.0 cm x 4.0 cm x 0.05 cm necrotic open area to right heel. Resident #55 continues with an unstageable pressure ulcer to the right heel with the last documented measurement on 01/20/20 of 1.5 cm x 2.0 cm described as a large tan area with a red center measuring 1.0 cm x 0.3 cm. Further review of Resident #55's medical record revealed no documentation of offloading interventions being put in place for his heels upon admission, on 08/26/19 and on 09/28/19 when pressure areas where again documented as being discovered. Review of Resident #55's physician orders [REDACTED]. Clean wound with wound cleaner, [MEDICATION NAME] and pat dry. Apply thin layer of Santyl (debridement ointment) and cover with island (waterproof) dressing, change daily. Obtain X-ray to right foot due to pain. Obtain a wound culture. An order dated 10/10/19 was may send to hospital for treatment and evaluations. Review of a facility document titled Nursing Transfer Sheet dated 10/10/19 revealed that Resident #55 had a 3.0 cm x 3.0 cm wound to his right heel. Resident #55 was receiving [MEDICATION NAME] 500 mg three times a day. Review of hospital records revealed that Resident #55 was admitted on [DATE] and treated for [REDACTED]. Resident #55 was discharged back to the facility on [DATE]. On 10/12/19 a right heel boot was added as an intervention. Review of a facility document titled Admission Data Collection Form dated 10/12/19 revealed Resident #55 had a right heel unstageable pressure ulcer measuring 5.0 cm x 1.0 cm. Review of a facility document titled Pressure Ulcer Risk Data Form dated 10/12/19 revealed Resident #55 scored a 10 indicating the resident was at risk for pressure ulcer development. Interview with Resident #55 on 01/21/20 at 9:16 [NAME]M. revealed that he had obtained a pressure ulcer to his right heel while at the facility and it was slowly going away. During an interview on 01/22/20 at 1:08 P.M. the Director of Nursing (DON) confirmed that wound documentation for Resident #55 on treatment administration records (TAR's) did not have any staging of wounds. The DON also confirmed Resident #55's heels were documented as being mushy on admission and there was a care plan identifying the areas as stage one pressure ulcers. The DON confirmed mushy heels should have been care planned and documented as deep tissue tissue injury (DTI). Resident #55's right heel was observed on 01/23/20 at 12:55 P.M. with Assistant Director of Nursing (ADON) #30 and Registered Nurse (RN) #69. Observation revealed an unstageable pressure ulcer measuring 1.3 cm x 2.4 cm x 0.1 cm. The wound was circular and covered in brown eschar with a small area pink center. ADON #30 and RN #69 confirmed the wound was unstageable due to eschar. ADON #30 stated Resident #55's right heel wound looked much better now and had been much worse. The DON confirmed during an interview on 01/23/20 at 2:00 P.M. there was no documentation of any offloading interventions being put in place for Resident #55's mushy heels on admission and on 09/28/19 when a soft reddish purple area was documented to his right heel. The DON also confirmed that staging of Resident #55's right heel wound was not completed weekly. The DON confirmed Resident #55 obtained the right heel unstageable pressure ulcer while at the facility and had recently to the hospital for an infection in the wound. Review of information from the NPUAP revealed a deep tissue pressure injury is intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use deep tissue pressure injury to describe vascular, traumatic, neuropathic, or dermatologic conditions. Further review of the NPUAP revealed staff should assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanter's, elbows and beneath medical devices, implement interventions to ensure that the heels are free from the bed and use heel offloading devices or [MEDICATION NAME] foam dressings on individuals at high-risk for heel ulcers.