Every finding on record at Mallard Creek Therapy and Living Center

Based on observation, interview, and record review, the facility failed to store, label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable, on 1 medication carts (hall 400 Nurses cart) and 1 medication room of 4 medication carts and 1 medication room reviewed for pharmacy services. The facility failed to ensure proper storage of acidophilus 1 billion (supplements used to support gut health and maintain a healthy balance of bacteria in the digestive tract) which required refrigeration per manufacturer's guidelines. The facility failed to ensure proper storage and disposal of Resident #100's Tylenol suppository 650mg when it was stored in the refrigerator in the medication room (Resident discharged date unknown) The facility failed to ensure proper storage and disposal of Resident #102s Tylenol suppository 650mg when it was stored in the refrigerator in the medication room (Resident discharged date unknown) The facility failed to ensure proper storage and disposal of Resident #103's Tylenol suppository 650mg when it was stored in the refrigerator in the medication room (Resident discharged date unknown) The facility failed to ensure proper storage and disposal of Resident #103's Bisacodyl 10mg suppository(fast-acting stimulant laxatives used for the temporary relief of occasional constipation) when it was stored in the refrigerator in the medication room (Resident discharged date unknown) These failures could place residents at risk of medication error, reduced therapeutic effectiveness, and potential adverse outcome due to improper storage and medication management practices administration of expired medication.Findings Include: The surveyor was unable to review the medical records of Resident #100, Resident#102, and Resident#103 because they were not available at the time of the survey. During an interview on [DATE] at 11:50 AM with Administrator and DON revealed that the current ownership assumed operations after 05/01/ 2026 and did not have access to medical records of residents who were discharged prior to that time. The surveyor was unable to verify the requested information through records review. An observation on [DATE] at 11:45 AM, with RN A of the medication room revealed medication labelled for Resident #100, Resident #102, and Resident #103 who had unknown discharge date s were found stored in the refrigerator in the medication room. In an interview on [DATE] at 11:47 AM, RN A stated she was unaware that Resident #100's Tylenol suppository 650mg, Resident #102's Tylenol suppository 650mg, and Resident #103's Bisacodyl 10mg suppository and Tylenol suppository 650mg who were discharged were still in the refrigerator in the medication room. She stated the nurses were responsible for ensuring all discharged residents' medication are removed as soon as the resident's discharge. She stated the risk to the residents was medication error because a discharged resident medication could be accidentally administered to another resident. She stated that she had been in-serviced on medication labeling and storage. An observation on [DATE] at 11:55 AM, of the 400 hall nurses' cart with RN B, revealed acidophilus, that required refrigeration, was stored unrefrigerated in the medication cart. In an interview on [DATE] at 11:57 AM, RN B stated she was unaware the acidophilus was supposed to be refrigerated. She stated the nurses were responsible for ensuring medication is properly stored and disposed. She stated the risk of not storing medication in the fridge that required refrigeration was the medication would lose its potency and be less effective when administered to the resident. She stated medication for discharged residents should be removed from the medication carts and medication room and disposed. In an interview on [DATE] at 11:04 AM, the DON stated nurses were responsible for ensuring medication was properly stored and all discharged residents were discharged with their medication or medication was removed from the medication carts and medication room. She stated if medication were supposed to be refrigerated it should be refrigerated because the medication could lose its effectiveness. She stated the risk of having discharged residents' medication in the medication cart could lead to medication errors. She stated that the nurses and medication aides had been in-serviced on medication storage. Review of the facility's policy Medication Access and Storage / Drug Destruction Revised [DATE] reflected the following: POLICY: Medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. PROCEDURES: Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Medications requiring refrigeration or temperatures between 2 C (36 F) and 8 C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists.CONTROLLED MEDICATION STORAGE At Each shift changed, a physical inventory of all controlled medication is conducted by licensed nurses and/or certified medication aides and is documented on the controlled substances accountability record.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and nutrition services. The facility failed to ensure an opened bottle of barbecue sauce was properly refrigerated after use in accordance with manufacturer instructions. The facility failed to ensure food items stored in the freezer were properly labeled with the contents after being removed from the original packages and dated to reflect when the food items were opened. The facility failed to ensure food packages stored in the freezer were properly sealed and secured. The facility failed to ensure frozen food items were protected from contamination, as evidenced by multiple individual-serving ice cream cups that had leaked, resulting in chocolate ice cream residue covering other individual-serving ice cream containers within the box. The facility failed to ensure frozen food items stored in the freezer were properly stored and protected, as evidenced by a box of frozen peas stored in an unsecured plastic bag and a box of chicken fritters with the original box opened and covered with an unknown red liquid substance.These deficient practices could affect residents who received meals or snacks from the kitchen and place them at risk for cross contamination and other food-borne illnesses. Findings included: Observation of the dry pantry on 06/30/2026 beginning at 8:50 AM, revealed a 1-gallon sized plastic container of BBQ sauce that was more than half used with an open date label of 06/24/26. The product manufacturer label indicated the sauce should be refrigerated after opening. The bottle was observed to be at room temperature. Observation of the freezer on 06/30/2026 beginning at 9:10 AM, revealed the following food items were not properly labeled with its contents or dated to reflect when the item was opened: 1 plastic bag of frozen hamburger patties and 1 plastic bag of chicken wings. Observation of the freezer on 06/30/2026 beginning at 9:10 AM, revealed the following food items were not properly sealed and secure: 1 package of frozen cookie dough, 1 package of frozen mixed vegetables, 1 package of frozen cut okra, 1 package of frozen southern style biscuit dough, 1 package of frozen peas, one package of frozen vegetable enchiladas, one package of frozen fish fillets and 1 bag of frozen hamburger patties. Observation of the freezer on 06/30/2026 beginning at 9:10 AM, revealed the following food items were not protected from contamination: 1 box of individual-serving chocolate ice cream cups. Observation of the box of ice creams revealed multiple cups that had leaked, resulting in chocolate ice cream residue covering the surrounding containers within the box. Observation of the freezer on 06/30/2026 beginning at 9:10 AM, revealed 1 frozen peas stored in an unsecured plastic bag had an unknown red liquid substance on the plastic bag and within the contents of the bag. Observation also revealed 1 box of chicken fritters stored in a plastic bag in a previously opened box had an unknown red liquid substance dripping down one side of the box and lid. During an interview on 06/30/2026 at 9:20 AM with the Dietary Manager, the observed food-related findings were reviewed with her, including items identified related to food storage, packaging integrity, labeling, and product condition. The Dietary Manager reported she did not know what the red liquid substance was in the freezer on the box of peas and chicken fritters or how long it had been there. She stated the items would be thrown away. She reported all food items should be stored in a secure and closed bag. She reported the container of BBQ sauce should always be refrigerated after opening. She reported she was not sure why it had not been refrigerated. The Dietary Manager was also shown the unlabeled bag of hamburger patties and chicken wings. She stated those should have had a label indicating the open date and expiration date. The Dietary Manager reported that herself and all dietary staff were responsible for ensuring all frozen items were labeled and stored securely. She reported all staff have been trained on food storage and safety. She stated she would conduct additional training on proper food storage. The Dietary Manager reported these findings could have caused food born illnesses and was an infection control risk to all residents. Review of the facility's undated policy titled Infection Control Policy/Procedure, reflected: It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illness. Director of food services responsibilities: Provide for the proper receipt and storage of all food supplies. Provide safe food services for residents and employees.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Resident#18, Resident#50, Resident#55), reviewed for infection control. 1.The facility failed to ensure MA C sanitized the blood pressure cuffs between (Resident#18, Resident#50, Resident#55), to prevent the spread of infections. 2.The facility failed to ensure a hospice aide transported clean linen by methods that ensure cleanliness. These failures could place residents at risk for healthcare associated cross contamination and infections. Findings include:Resident #18's1. Record review of Resident #18's Quarterly MDS Assessment, dated 05/05/26, reflected a [AGE] year-old female. Resident #18 had a BIMS score of 04, which indicated she had severe cognitive impairment. The resident had diagnoses which included hypertension (High blood pressure[VT11.1])Record review of Resident #18's Comprehensive Care Plan, edited 05/01/26, reflected [Resident #18] has hypertension. Interventions included: Give anti-hypertensive medications as ordered. Monitor for side effects such asorthostatic hypotension (a sudden drop in blood pressure that occurs when standing up from a sitting or lying position) and increased heart rate.Record review of Resident #18's Physicians orders, dated 07/02/2026, reflected: hydrochlorothiazide (prescription medication for treating high blood pressure) Oral Tablet 12.5 MG (Hydrochlorothiazide) Give 1 tablet by mouth one time a day for HTN (High blood pressure) HOLD FOR SBP LESS THAN 110 OR DBP LESS THAN 60 Verbal Active 05/01/2026.Resident #50'sRecord review of Resident #50's Quarterly MDS Assessment, dated 05/14/26, reflected a [AGE] year-old female. Resident #50 had a BIMS score recorded indicating no BIMS interview was conducted. The resident had diagnoses which included hypertension.Record review of Resident #50's Comprehensive Care Plan, edited 05/31/26, reflected: Resident #50 had hypertension r/t disease process. Interventions included: Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (a sudden drop in blood pressure that occurs when standing up from a sitting or lying position) and increased heart rate.Record review of Resident #50 Physicians orders, dated 07/02/2026, reflected: Metoprolol Succinate ER (prescription medication for treating high blood pressure) Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 1 tablet by mouth one time a day for hypertension.HOLD FOR SBP LESS THAN 110 OR DBP LESS THAN 60. HOLD FOR PULSE LESS THAN 60 Active 04/24/2026.Resident #55'sRecord review of Resident #55's Quarterly MDS Assessment, dated 05/12/26, reflected a [AGE] year-old female. Resident #55 had no BIMS score recorded indicating no BIMS interview was conducted. The resident had diagnoses which included hypertension.Record review of Resident #55's Comprehensive Care Plan, edited 05/12/26, reflected there were no focus areas, goals or interventions related to blood pressure identified on the care plan.Record review of Resident #55 Physicians orders, dated 5/20/2025, reflected: Amlodipine Besylate (prescription medication for treating high blood pressure) oral table 5mg give 1 tablet by mouth two times a day for HTN HOLD FOR SBP LESS THAN 110 OR DBP LESS THAN 60; HOLD FOR PULSE LESS THAN 60. Active 04/30/2026.An observation on 07/01/2026 at 8:30 AM revealed MA C checked Resident #18's Blood Pressure but did not sanitize the blood cuff.An observation on 07/01/2026 at 08:36AM revealed MA C checked Resident #50's Blood Pressure but did not sanitize the blood pressure cuff.An observation on 07/01/2026 at 8:56AM revealed MA C checked Resident #55's Blood Pressure, did not sanitize the blood pressure cuff and placed it in the cart.An interview on 07/01/2026 at 10:36 AM with MA C revealed she was supposed to sanitize the blood pressure cuff after use with each resident. She stated the failure to sanitize the blood pressure cuffs could put the residents at risk for infection and contamination of other items in the medication cart.An observation on 07/01/2026 at 8:30 AM revealed a hospice CNA carrying linen against her body while transporting it to Resident #55's room rather than placing the linen in bag to protect it from contamination.An interview on 07/01/2026 at 8:32 AM with hospice CNA revealed she was going to give Resident #55 a shower. She stated that she should have put the linen in a bag before transporting the linen. She stated the risk to the resident was contamination and transmitting infections.An interview on 07/02/2026 at 11:39 AM with DON revealed her expectation was that the staff sanitized blood pressure cuffs after use on each resident, and all linen was transported in bags and not held against the staff's body. She stated the failure to sanitize the blood pressure cuff after each use, and the failure to transport linen in a clean manner would place residents at risk for infections. She stated the staff were in-serviced on infection control.Review of the facility's policy Infection Prevention and Control Program Revised 04/2025 reflected the following: 2. Process Surveillance is the review of practices by staff directly related to resident care. Some considerations for this process may include but are not limited to: e. Infection control practices during the provision of residents' care and treatmentsg. Cleaning and disinfection production and procedures for environmental surfaces and equipment.i. Linen management (Handling, storage, processing, and transport). 4.Facility personnel will handle, store, process, and transport linen so as to prevent the spread of infection 6. The facility will provide equipment and supplies to implement its infection control program with the goal of: a. Ready availability of hand cleaning supplies and paper towel at each sinkb. Safe use of disposal and single use supplies and equipmentc. Effective cleaning and disinfecting equipment as needed, to include bathing areas between each resident's use.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (Day Room) out of 1 Day Room reviewed for accidents and hazards. The facility failed to ensure that 1 of 1 mechanical lift in the Day Room was locked, secured, and stored in a secure designated area when not in use. This failure could place residents, visitors and staff at risk of falls and/or injuries.Findings included: Observation of the facility's Day Room (a common area for residents to gather) on 07/01/26 at 8:43AM revealed a mechanical lift stored toward the entrance of the room, with the breaks unlocked. One resident was observed attempting to go into the Day Room at that time. During an interview with the ADON on 07/01/26 at 8:43AM, she verified the breaks of the mechanical lift were unlocked. The ADON stated mechanical lifts should be locked and stored away from residents in their designated location, which she identified as the charging station which was in the corner of the Day Room. The ADON stated the risk of the mechanical lift being left unlocked and toward the entrance of the Day Room included potential injury to residents. During interviews with CNA D and CNA E on 07/01/26 between 10:20AM and 10:25AM, they both stated mechanical lifts should be locked and stored away from residents in their designated location. They both stated the risk of a mechanical lift being left unlocked and toward the entrance of the Day Room included potential injury to residents. Record review of the facility's Mechanical Lift and Slings policy, undated, reflected no information pertaining to the appropriate storage of mechanical lifts. The Administrator stated on 07/02/26 at 10:47AM that the facility did not have any additional policies related to mechanical lift storage or safety.

Based on observations, interviews, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for two (Resident #16 and Resident #47) of five residents reviewed for respiratory care. 1.) The facility failed to ensure that Resident #16's nebulizer mouthpiece was bagged in a plastic bag and stored in a drawer, which was consistent with professional standards. 2.) The facility failed to ensure that Resident #47's nebulizer mouthpiece was bagged in a plastic bag and stored in a drawer, which was consistent with professional standards. These failures had the potential to affect residents receiving respiratory therapy by increasing their risk of health-associated infections.Findings included: 1.) Record review of Resident #16's Face Sheet, dated 07/02/26, reflected she was an [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe) and obstructive sleep apnea (a common sleep disorder where your airway repeatedly becomes blocked or narrows during sleep, stopping or significantly reducing your breathing). Record review of Resident #16's MDS Assessment, dated 05/29/26, reflected she had a BIMS score of 14, indicating she was cognitively intact. The assessment reflected she received respiratory treatments while a resident at the facility. Record review of Resident #16's Physician's Orders, dated 07/02/26, reflected an active PRN order for DuoNeb Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol); 1 applicator - inhale orally every 6 hours as needed for SOB/Wheezing. The start date for this order was 05/01/26. Record review of Resident #16's Care Plan, dated 05/01/26 (but active as of 07/02/26), reflected she received oxygen therapy due to her diagnosis of chronic obstructive pulmonary disease. Observation of Resident #16's nebulizer equipment on 06/30/26 at 10:13AM revealed her nebulizer mouthpiece was lying on her bed, unbagged. Resident #16 was not in her room. 2.) Record review of Resident #47's Face Sheet, dated 07/02/26, reflected she was an [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe). Record review of Resident #47's MDS Assessment, dated 06/08/26, did not reflect she received respiratory treatments. Record review of Resident #47's Physician's Orders, dated 07/02/26, reflected an active order for Arformoterol Tartrate Inhalation Nebulization Solution 15 MCG/2ML (Arformoterol Tartrate); 1 application - inhale orally two times a day for SOB. The start date for this order was 05/28/26. Record review of Resident #47's Care Plan, dated 05/28/26 (but active as of 07/02/26), reflected no evidence that Resident #47's order for nebulizer treatment was in the plan of care. Observation of Resident #47's oxygen equipment on 06/30/26 at 10:15AM revealed her nebulizer mask was lying on her nightstand, unbagged. During an interview with the DON-in-Training on 06/30/26 at 10:50AM, she verified that Resident #16 and Resident #47's nebulizer equipment was not stored properly. She stated nursing staff were responsible for ensuring nebulizer equipment was properly stored in plastic bags when not in use. She stated the risk of improperly stored nebulizer equipment included the potential for infection. Record review of the facility's Oxygen Equipment policy, dated 05/2017, reflected, .Procedures:. 2. Nebulizer Equipment Procedures A. Nebulizer equipment generates aerosols small enough to be readily deposited in the lungs. Careful technique is required to prevent infecting the resident. B. Medication will be added to the nebulizer immediately before use. C. After each treatment, take the nebulizer apart and discard all unused medication. Rinse all parts thoroughly with warm water and air dry. D. Daily dismantle entire breaking assembly including all hoses, wash with warm soapy water, rinse well and ensure parts are dry, including inside of hoses. E. Reassemble pieces. F. Store, clean, and dry until next time.

Based on observation, interview, and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 1 Resident (Resident# 52) of 10 Residents reviewed for pharmacy services. The facility failed to ensure proper disposal of Resident #52's Lorazepam Oral (prescribed for the short-term relief of anxiety, trouble sleeping, or acute stress) Tablet 0.5mg (controlled medication) by taping narcotic medication and storing it in the 400-hall medication cart. These failures could place residents at risk of drug diversion, medication error, and risk of pills contamination due to broken seals.Findings included:Resident#52 Review of Resident #52's Quarterly MDS Assessment, dated 06/18/2026, reflected an [AGE] year-old male admitted on [DATE]. He had a BIMS score of 4, indicating he had severe cognitive impairment. The resident had diagnoses which included non-Alzheimer's disease. Review of Resident #52's Comprehensive Care Plan, initiated 05/20/2026, reflected: Anti-anxiety medication uses r/t Anxiety disorder AEB NERVOUSNESS/RESTLESSNESS. Interventions included: Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness.Review of Resident #52's active physician orders dated:07/02/2026 reflected Lorazepam Oral Tablet 0.5 MG Give 1 tablet by mouth every 6 hours as needed for anxiety or agitation -order start date 07/01/2026 and Stop date 07/14/2026. Observation on 06/30/26 at 11:55 AM, of the 400 hall nurses' carts with RN B indicated Resident # 52's Lorazepam Oral Tablet 0.5 MG had one broken seal and the blister pack secured with tape. The damaged blister packs had the pills still inside at the time the surveyor inspected the medication cart. During an interview on 06/30/26 at 11:59 AM, RN B stated the nurses were responsible for checking the medication blister packs for broken seals during the count of narcotics at change of shift. She stated that she was not aware the narcotics were taped. She stated that the risk of a damaged blister would be potential for drug diversion, medication not being effective and contamination of the medication. She stated she had been in-serviced on medication storage.During an interview on 07/02/26 at 11:04 AM, the DON stated nurses were responsible for ensuring medication carts were clean and all narcotic medication was properly secured and no narcotics should be taped. She stated that the consultant pharmacist audited the medication carts monthly, then the pharmacy consultant checked the medication room, and the medication cart every month. She stated the risk was that the nurses would not know if the taped pill was the correct medication. She stated the nurses had been in-serviced on medication administration and narcotic count to include no taping medication but disposing the medication witnessed by another nurse.Review of the facility's policy Medication Access and Storage / Drug Destruction Revised 11/13/2018 reflected the following: Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists.CONTROLLED MEDICATION STORAGE At Each shift changed, a physical inventory of all controlled medication is conducted by licensed nurses and/or certified medication aides and is documented on the controlled substances accountability record.