Every finding on record at Mountain View Health Care

Based on observations, staff interviews, and review of the facility's policies titled, Sanitizing the Ice Machine and Supplies, and Date and Label, the facility failed to appropriately label, date, discard expired food items, and failed to maintain an ice machine under sanitary conditions in one of one kitchen. The deficient practice increased the risk of foodborne illness for 71 residents who received an oral diet from the kitchen.Findings Include:Review of facility's policy titled, Sanitizing the Ice Machine and Supplies dated 02/2025, documented, .If ice is not handled properly, ice can become contaminated and may result in illness and or death. Equally important is to understand steps to sanitizing the ice machine and all other equipment that may meet ice that may potentially contaminate the ice.Review of facility's policy titled, Date and Label dated 01/2026, documented .1. FIFO (First In, First Out) - Date each package or container with the delivery date. Place newest similar products behind the older similar products, allowing the product that has been on the shelf longer to be used first. Review the expiration or used by dates on all products as these items should be used first or discarded if the expiration or used by date has passed. 2. All food delivered in boxes, packages, containers, cans, or other original packaging will have the delivery date indicated on the packaging. 3. RTE (Ready to Eat), refrigerated and / or Time/Temp Control Food (food that contains ingredients that may cause food poisoning) will have an (1) Open or Prepared Date, (2) Discard date on each of food. If the food is delivered RTE, the delivery date will be documented on the packaging.During the initial inspection conducted on 07/10/2026 at 7:50 AM, it was observed that several food items within the dry storage area of the kitchen lacked proper labels and dates. These items included one 10-pound package of spaghetti pasta, one 3-pound container of French-fried onions, one 5-pound bag of yellow cake mix, one 2-pound package of breadcrumbs, and one 5-pound bag of instant potatoes. Observed in the reach in freezer was a pack of 6-count pizza crusts without any labeling or dating. The stand-alone reach-in refrigerator revealed one pan of vanilla pudding labeled with a use-by date of 07/09/2026, containing 78 four-ounce cups. Additionally, there was a four-quart container labeled as pears with a use-by date of 07/09/2026. On the rack, there were 11 hydration items, which included 10 nectars dated 07/09/2026, three buttermilks dated 07/08/2026 and 07/09/2026, one tomato juice, and one water, all lacked proper labeling. Inside the walk-in refrigerator, one gallon of milk was found with an expiration date of 07/07/2026, one four-quart container of jelly with an expiration date of 07/09/2026, and four 32-ounce containers of heavy whipping cream with expiration dates of 07/06/2026 and 07/08/2026. All food items were confirmed by the Administrator.A follow-up kitchen tour on 07/11/2026 at 11:35 AM, conducted with the Dietary Manager (DM), included an inspection of the ice machine. The DM performed the inspection while wearing gloves and utilized a white paper towel and wiped the interior of the ice machine. The DM confirmed the presence of a reddish substance on the napkin and stated that maintenance was supposed to have cleaned it, but it had not been done.On 07/12/2026, at 9:27 AM, an interview was conducted with Dietary Aide (DA) BB, who confirmed that she prepared the hydrations for trays and that she was not in-serviced on putting received date, open date, nor expiration date; she was only informed to place open or prepared date.On 07/12/2026, at 9:36 AM, an interview with the Assistant Dietary Manager indicated that she and the Dietary Manager were responsible for checking the labeling and dating, since the staff are unsure of what dates to apply and rely on them to finalize or dispose of items.On 07/12/2026, at 9:56 AM, an interview and review of photographs with the DM confirmed that the items were improperly dated and some items lacked complete dating or were missing expiration dates altogether. The DM acknowledged that this situation could pose a risk to residents' health.

Based on record review, staff interviews, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to ensure that one of 33 sampled residents (R) R70, was free from misappropriation of resident's property. The deficient practice created the potential for other residents to experience misappropriation and negative financial consequences for R 70.Findings include:Review of the facility policy titled, Abuse, Neglect, Exploitation revised 2017, documented, Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation.Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Documented for Policy Explanation and Compliance guidelines, .10. Exploitation means taking advantage of a resident for personal gain through the use of manipulation intimidation, threats, or coercion. 11. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrong temporary or permanent, use of a resident's belongings or money without the resident's consent.Review of the Face Sheet revealed that R70 was admitted [DATE] and readmitted [DATE], with diagnoses that included, but not limited to, other acute osteomyelitis, left ankle and foot, acute on chronic systolic (congestive) heart failure, obstructive sleep apnea, chronic atrial fibrillation, hereditary and idiopathic neuropathy, chronic kidney disease, stage 3B.Review of the admission Minimum Data Set (MDS) for R70 dated 04/13/2025, revealed that the R70 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated little to no cognitive impairment.Interview on 07/11/2026 at 9:26 AM, with Complainant AA revealed he had suspicion that the business office manager wrote checks from R70's checking account and cashed them.An interview on 07/11/2026 at 10:53 AM with R70 revealed that the entire situation regarding his finances was confusing. R70 mentioned the former business office manager discussed her financial difficulties with him. R70 stated he lent her approximately two thousand dollars. R70 clarified that she was supposed to repay the loan and doubted he would receive money back.An interview conducted on 07/11/2026 at 2:41 PM, with the Administrator confirmed the previous business manager exploited R70 and it was discovered 08/14/2025.

Based on record review, resident and staff interviews, and review of the facility policy titled, Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, the facility failed to thoroughly investigate misappropriation of resident's property for one of 33 sampled residents (R) R70. The deficient practice increased the risk for other misappropriation.Findings include:Review of the facility policy titled, Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating revised 09/2022 documented in the Policy Statement, All reports of resident abuse.exploitation, or theft/misappropriation of resident property are reported.and thoroughly investigated by facility management. Documented in Investigating Allegations, 1. All allegations are thoroughly investigated.7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence.h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident.j. interviews other residents to whom the accused employee provides care of services. Review of the Face Sheet revealed that R70 was admitted [DATE] and readmitted [DATE], with diagnoses that included, but not limited to, other acute osteomyelitis, left ankle and foot, acute on chronic systolic (congestive) heart failure, obstructive sleep apnea, chronic atrial fibrillation, hereditary and idiopathic neuropathy, chronic kidney disease, stage 3B.Review of the admission Minimum Data Set (MDS) for R70 dated 04/13/2025, revealed that the R70 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated little to no cognitive impairment.Record review of the Facility Incident Report provided by the Administrator revealed it was dated 08/14/2025. Further review revealed that the Incident Report documented the report served as the Investigative Report and the five-day summary of the report of alleged financial misappropriation of R70 reported to the State Survey Agency (SSA). Documentation included a statement from the family representative of R70 that alleged R70 had checks cashed by Business Office Manager. In addition, the investigation documents included that staff reported an ATM withdrawal on 07/21/2025 of $400.00 and a check dated 06/06/2025 in the amount $2000.00. The investigation included a statement from the Business Office Manager. An interview on 07/11/2026 at 10:53 AM with R70 revealed that the entire situation regarding his finances was confusing. R70 mentioned the former business office manager discussed her financial difficulties with him. R70 stated he lent her approximately two thousand dollars. R70 clarified that she was supposed to repay the loan and doubted he would receive money back.In an interview on 07/12/2026 at 8:45 AM, the Administrator stated she did not conduct interviews with other residents after the allegation of misappropriation of property by R70. She stated she thought that since the resident's money was not in a resident trust account and was in his personal account, she didn't need to.During an interview conducted on 07/12/2026, at 10:51 AM, with Director of Nursing (DON) it was confirmed that she was made aware of the misappropriation of R70 at the same time as the Administrator. The DON confirmed there were no interviews conducted with other staff or residents.

Based on observations, staff interviews, and review of facility policies, the facility failed to ensure staff wore proper hair restraints in the kitchen, ensure proper temperatures of the dishwasher, ensure staff wore gloves during food preparation, ensure food items were dated and discarded on or before expiration dates, ensure sanitary conditions in the kitchen, prevent cross-contamination of food items, and ensure hot food temperatures were monitored and documented, These deficient practices had the potential to place the 77 residents who received meals from the kitchen at increased risks of a foodborne illness. Findings include: Review of the facility's policy titled, Food Safety Requirements, dated 11/1/2022, revealed Hairnets should be worn when cooking, preparing, or assembling food. Review of the facility's policy titled Food Safety Requirements, dated 11/1/2022, revealed Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas. Review of the facility's policy titled, Date and Label, dated 3/2025, revealed 3. Write the delivery date on each can .6. Discard food that has expired or passed the used by date. 7. Discard food that does not have a delivery date indicated on the product or box. Review of the facility's policy titled Sanitation of the Storeroom, Freezer and Coolers, dated 3/2024 indicated .It is the policy of the facility to keep food storage areas clean and sanitary to ensure food remains safe to prepare and consume. Review of the facility's policy titled, Cleaning and Sanitizing the Storerooms/ Freezer/ Refrigerator, dated 3/2024, revealed b. Walls and floors will be clean and rodent proof. Review of the facility's policy titled, Food Safety Requirements, dated 11/1/2022, revealed Clean dishes shall be kept separate from dirty dishes. Review of the facility's policy titled, Food Safety Requirements, dated 11/1/2022, revealed Additional strategies to prevent foodborne illness include, but are not limited to: a. Preventing cross-contamination of foods. Review of the facility's policy titled, Standardized Recipes, dated 3/2025, revealed 1. Recipes contain the following: a. Ingredients and amounts required for the recipe. b. Preparation method. c. Other preparation information .e. Temperature to prepare and serve the food. 2. Dietary Manager will provide recipes for the foods to be prepared .4. Prior to service, the cook preparing the meal will take the temperature of the food .appropriate texture and temperature prior to serving the meal. 1. An initial tour of the kitchen was conducted on 6/23/2025 at 8:55 am. The Dietary Manager (DM) presented with her hair partially restrained. The hair net covered the back of her head, and the front of her head hung large pieces of hair which framed her face. A test was run on the dish machine and the DM stated the temperature for the dish machine wash cycle was to be 50 degrees Fahrenheit (F) and for the rinse cycle it was to be 90 degrees F. During this observation, the staff conducted a test run of the dish machine. The temperature for the wash cycle was 98 F, and 100 F for the rinse cycle. The DM confirmed the temperatures. Observation revealed that both the wash and rinse cycle were to be at 120 F. During this tour, observation revealed two free standing box freezers. There was no temperature log available. When the freezers were opened both had heavy ice built up around the edges of the freezers on all four sides. Review of a document provided by the facility titled Dish machine Temperature Log, revealed for the month of 6/202 the following missing dates of recorded temperatures: 06/21/2025, 6/22/2025, and 6/23/2025. During an interview with the Maintenance Director on 6/23/2025 at 9:20 am, he checked the dishwasher temperature and stated the dishwasher was running at 104 F. The Maintenance Director stated he was aware that the dish machine needed to be at 120 F for effective sanitation. The Maintenance Director stated he was instructed by the Administrator to turn the water down for the entire building to 110 F. 2. Observation in the dining room on 6/23/2025 at 12:36 pm, revealed Licensed Practical Nurse (LPN) 1 cutting an unidentified resident's peanut butter and jelly sandwich while holding the sandwich with her bare hands. Further observation revealed she handed the sandwich to the resident with bare hands. During an interview on 6/23/2025 at 12:48 pm, LPN 1 stated she was aware she should not touch ready-to-eat food with bare hands and acknowledged she touched the sandwich with her bare hands before handing it to the resident. 3. During observation of the kitchen dry storage area with the Dietary Manager (DM) on 6/25/2025, beginning at 9:12 am, the following were observed in the emergency food stock area: -One large can (6.75 pounds) of corned beef hash with a best by date of 6/14/2025. The DM confirmed the item was expired and proceeded to dispose of the item. -Four large cans (6-pound 12-ounces) of beef ravioli with a best by date of 6/03/2025. The DM confirmed they were expired and proceeded to throw them out. -One large can (6-pound 10-ounces) of pineapple chunks with a date of 1/14/2020. The DM confirmed it was expired and proceeded to throw it out. She stated she did not have a shelf-life list and confirmed the additional identified items did not have an expiration date marked: -One case of orange juice with 12-boxes (33.8-ounces) with no expiration dated listed. -One crate of orange juice and cranberry cocktail -over 10-boxes, with no expiration dates listed. -Several boxes of cream of wheat dated as expired in November with no year provided. The DM confirmed she was unable to tell when the items were expired. She stated she had not had to be in the dry storage area and had not checked the dates. She acknowledged it was her responsibility to check for expired foods. 4. Observation on 6/25/2025 at 10:17 am, revealed Registered Nurse (RN) 2 in the kitchen, making sandwiches. Further observation revealed she did not have a hairnet or other hair covering on. The DM was also observed with hair coming out the front of her hairnet. In an interview the DM acknowledged her hairnet did not fit right and RN 2 did not have a hairnet or hair covering on. 5. Observation on 6/25/2025 at 10:32 am, revealed a very large fan to the right back of the kitchen area, built into the wall. The fan was blowing air into the kitchen with no screen or cover, and open to the outside. Observation revealed the fan was covered in lint and leaves along the bottom inside of the fan. There was a blending station for the mechanically altered diets on a table directly in front of the fan. The DM stated the fan blew constantly because it was so hot in the kitchen. She stated they shut the fan off at night. Observation on 6/25/2025 from 10:30 am to 10:41 am, revealed clean knives were stored in front of a dirty wall with food spatter. The knives were also stored to the left side, on the wall right behind the 4-pan sink (dirty dish side). There was a bar above the 4-pan sink which stored the clean utensils, spatulas, and ladles. This was in close proximity to the areas of the dishwashing process. The piping to the right side of the grill top had thick caked on grease. This area was attached to the grill top and to the left of the fryer. The wall behind the mechanically altered prep station was dirty with thick layers of food spatter. During an observation and interview on 6/25/2025 at 3:17 pm, the DM confirmed all of the above observations and confirmed the areas needed to be cleaned and the knives and utensils needed to be moved. 6. Observation on 6/25/2025 at 11:33 am, revealed [NAME] 3 removed yams from the oven and checked the temperature of the yams, did not clean the thermometer afterwards, and used the same thermometer to check the temperature of ham without sanitizing the thermometer between the food items. 7. Review of the Food Temperature Log, provided by the facility and dated for June 2025, revealed only two days documented for meal temperatures on 6/1/2025 and 6/19 with no year. One log provided by the facility was dated 6/18/2022. The Temperature Log during the week of survey did not include any documentation for mechanically altered textures. Observation on 6/25/2025 at 11:58 am, revealed [NAME] 3 making the ground texture of the ham and placed directly onto the steam table, without ensuring proper temperature. Continued observation revealed she made another batch of ground ham and placed it into the pan on the steam table, without ensuring proper temperature. This process was completed a third time. Observation on 6/25/2025 at 12:04 pm, revealed [NAME] 3 preparing pureed ham. She placed the pureed ham into a pan and placed it onto the steam table without ensuring proper temperature. She then prepared pureed beets and placed them onto the steam table without ensuring proper temperature. At 12:40 pm, a test tray was conducted with the DM, directly from the steam table. The pureed ham was 123 degrees F. During an interview on 6/25/2025 at 3:30 pm, the DM confirmed the food log sheets were missing documentation of food temperatures. During an interview with the Administrator, the Regional Administrator, and the DM on 6/26/2025 at 8:57 am, the Regional Administrator confirmed the knives should be stored in a clean area of the kitchen. She stated dietary staff should use the first-in first-out system in the kitchen. She further stated she would like to move access to hairnets in kitchen. The DM stated alcohol pads had always been available for the kitchen staff to use to clean the thermometers between foods. The Regional Administrator stated they needed to retrain dietary staff and monitor for compliance.

Based on staff interviews, record review, the facility failed to issue the notice for termination of Medicare Part A benefits, with correct information, for three of three residents (R) (R65, R43, and R131). Findings include: 1. Review of R65's electronic medical record (EMR) titled admission Record located under the profile tab indicated that the resident was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of R65's EMR titled significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/8/2024 located in the survey shell, indicated the resident had a Brief Interview for Mental Status (BIMS) score of seven out of 15 which revealed the resident was severely cognitively impaired. Review of documents provided by the facility titled Notice of Medicare Non-Coverage (NOMNC), for R65, indicated the notice informed the resident that skilled services would end on 1/13/2025. Review of a document provided by the facility titled Physical Therapy PT (Physical Therapy) Evaluation & Plan of Treatment dated 12/2/2024 indicated R65 began skilled services. Review of a document provided by the facility titled Physical Therapy PT Discharge Summary dated 12/30/2024 indicated R65 ended skilled therapy services. This contradicts the dates of coverage identified for R65's NOMNC. During an interview on 6/25/2025 at 11:17 am, the Director of Rehabilitation (DOR) confirmed R65 was on therapy skilled services from 12/2/2024 to 12/30/2024. 2. Review of R43's EMR titled admission Record located under the Profile tab indicated the resident was initially admitted to the facility on [DATE] and recently admitted to the facility on [DATE]. Review of R43's 5-day MDS dated 12/9/2024 indicated the resident had a BIMS score of 11 out of 15, which revealed the resident was moderately cognitively impaired. Review of documents provided by the facility titled NOMNC, for R43, indicated the notice informed the resident that skilled therapy services would end on 1/22/2025. Review of documents provided by the facility titled Physical Therapy PT Evaluation & Plan of Treatment dated 12/3/2024 for R43 indicated the resident began skilled services. Review of documents provided by the facility titled Physical Therapy PT Discharge Summary dated 1/20/2025 for R43 indicated the resident ended skilled services. This contradicts the dates of coverage identified for R43's NOMNC. During an interview on 06/25/2025 at 11:17 am, the DOR confirmed R43 was on skilled therapy services from 12/2/2024 to 1/20/2025. 3. Review of R131 EMR titled admission Record located under the Profile tab indicated the resident was initially admitted to the facility on [DATE] and was recently admitted to the facility on [DATE]. Review of documents provided by the facility titled NOMNC, for R131, indicated the notice informed the resident that skilled therapy services would end on 2/11/2025. Review of documents provided by the facility titled Physical Therapy PT Evaluation & Plan of Treatment dated 11/12/2024 for R131 indicated that the resident began skilled services. Review of documents provided by the facility titled Physical Therapy PT Discharge Summary dated 1/3/2025 for R131 indicated the resident ended skilled services. Review of documents provided by the facility titled Speech Therapy SLP (Speech Language Pathology) Evaluation and Plan of Treatment dated 12/6/2024 for R131 indicated the resident began skilled services. Review of documents provided by the facility titled Speech Therapy SLP Discharge Summary dated 1/21/2025 for R131 indicated the resident ended skilled services. During an interview on 6/25/2025 at 11:17 am, the DOR confirmed R131 was on skilled therapy services from 11/11/2024 to 1/21/2025. During an interview on 6/25/2025 at 10:33 am, the BOM stated she was still learning aspects of her position and the NOMNC notifications. During an interview on 6/25/2025 at 10:58 am, the BOM stated she places calls to the residents' family members and has discussions with them about skilled therapy services. The BOM stated part of her responsibility was to look up Medicare days available for the residents. During an interview on 6/25/2025 at 2:32 pm, the Administrator stated it was a collaboration among the therapy department, business office, and the MDS Coordinator (MDSC) to determine the dates of skilled therapy coverage. The Administrator stated that the Regional [NAME] Specialist (RBS) trained the BOM. The Administrator further stated she was unaware of the inaccurate dates of skilled therapy coverage for three of the residents. During an interview on 6/26/2025 at 10:49 am, the RBS stated it was important for the residents to be informed about the end of skilled services and to understand their rights under the appeal process. The RBS was asked if the skilled therapy services were to match the dates of skilled services on the NOMNC, and the RBS provided no response.

Based on observations and staff interviews, the facility failed to ensure that essential equipment in the kitchen and laundry room was functioning. Specifically, one reach-in refrigerator in the kitchen, one of two washing machines, and two of three clothes dryers in the laundry were not in operable order. This deficient practice had the potential to affect adequate food production and laundry production in the facility. Findings include: 1. During an observation and interview on 6/25/2025 at 11:14 am, the Dietary Manager (DM) stated that the tall reach-in refrigerator, located to the left when walking into the kitchen, was broken. She stated the refrigerator malfunctioned on 6/24/2025. The DM checked the interior temperature of the refrigerator, and it was 48 degrees Fahrenheit (F). The DM further stated that the kitchen got very hot. At 11:18 am, Cook3 confirmed the temperature in the kitchen was 90 degrees F. During an interview on 6/25/2025 at 1:36 pm, the Maintenance Supervisor stated the reach-in refrigerator was working on Monday, and the morning after, it went down. He stated he thought it was the thermostat. He further stated that water was found in it, and he guessed it had gotten too hot. During an interview on 6/26/2025 at 8:57 am with the Administrator, the Regional Administrator, and the DM, the DM stated that they got the refrigerator in October or November 2024. The Administrator stated she knew the kitchen was warm. 2. During a tour of the facility laundry room on 6/26/2025 beginning at 9:52 am, the Housekeeping Manager stated that two of the three facility dryers and one of the two industrial washing machines were not working. The Housekeeping Manager stated that one of the two dryers had not worked for the past year, and this had impeded her and her staff's ability to keep up with the laundry demands of the facility. The Housekeeping Manager stated she was unsure when the washing machines stopped working. The Housekeeping Manager stated that the Maintenance Director has worked on these machines. Observation in the laundry room revealed eight barrels of soiled resident clothing and linen, one three-compartment linen hamper full of soiled resident clothing and linen, and three large black bags full of soiled kitchen rags. In an interview, the Laundry Aide and Housekeeping Manager stated that they were unable to complete all the laundry when the washer and dryers were not functioning. During an interview on 6/26/2025 at 10:15 am, the Maintenance Director stated he began his employment at the facility on 11/11/2024, and the machines were down then. The Maintenance Director stated that he had requested a new washer and was informed that it was on its way. During an interview on 6/26/2025 at 10:33 am, the Administrator stated she was aware that the washer and dryers were down in the laundry room, and she had been reporting this to her boss on a weekly basis. The Administrator stated she was unaware of the backlog of soiled laundry as a result of the non-working machines. The Administrator stated that the laundry staff need functioning equipment to be able to perform their jobs.

Based on observations, staff interviews, and review of the facility's policy titled Pest Control Policy, the facility failed to ensure the kitchen remained free from pests in one of one kitchen. This failure had the potential to affect the sanitary environment in which food was prepared for 77 residents who consumed food in the kitchen. Findings include: Review of the facility's undated policy titled Pest Control Policy revealed Facility will utilize a variety of methods in controlling certain seasonal pests .These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations. During an observation and interview on 06/25/2025 at 10:32 am, the observation revealed a very large fan to the right back of the kitchen area. The fan was built into the wall. The fan appeared to be blowing air into the kitchen with no screen or cover, completely open to the outside. The fan was covered in lint and leaves along the bottom inside. There was a blending station for the mechanically altered diets on a table directly in front of the fan. The Dietary Manager (DM) stated the fan blew constantly because it was so hot in the kitchen. She stated they shut the fan off at night, and the back of the fan was supposed to close off access to the outside. She stated pest control was at the facility the day before. During an observation on 06/25/2025 at 10:55 am, the prep table in front of the open fan contained three dead insect carcasses. There were two additional brown pieces on the prep table. During an observation and interview on 6/25/2025 at 11:42 am, a bug was observed walking underneath the stove area. Cook1 confirmed the bug. She removed it with a paper towel. At 11:44 am, observation revealed a dead bug in the left corner of the kitchen, to the right of the four-pan sink. The DM picked it up with a paper towel and stated it was a cockroach. During an observation and interview on 6/25/2025 at 1:36 pm, the DM stated they were getting an air conditioner installed on this day. The Maintenance Supervisor stated pest control had come in the day before, and they were in the kitchen at least three times a week. He acknowledged the large fan was open to the outside and that maybe they should get rid of the fan. During an interview on 6/26/2025 at 12:14 pm, the Administrator stated they had identified pest control as a concern prior to the survey, but did not identify the large fan, open to the outside, as a potential entrance for insects or pests.

Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure one of one resident (R) (R44) reviewed for respiratory services received oxygen as ordered by the physician out of a total sample of 37 residents. This failure placed the resident at risk of receiving insufficient oxygen to meet the assessed respiratory need. Findings include: Review of the facility's policy titled, dated October 2010, stated Review the physician's orders or facility protocol for oxygen administration .Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: .(3) The rate of oxygen flow, route, and rationale. Review of R44's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R44 was admitted to the facility on [DATE] with diagnoses, which included chronic respiratory failure. Review of R44's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/1/2025, located under the RAI tab, showed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R44 was cognitively intact. R44 was documented to be administered oxygen while a resident. The resident was revealed not to reject care. Review of R44's electronic medical record (EMR) under the Orders tab revealed a 6/3/2024 physician order for Oxygen at one liter a minute via nasal cannula, continuously monitor oxygen saturation each shift if below 90% [percent], notify MD (physician) every shift related to chronic respiratory failure. Review of R44's EMR under the Orders tab revealed the June 2025 Medication Administration Record (MAR) failed to document the oxygen flow rate. Review of R44's EMR under the Weights/Vitals tab revealed the resident's oxygen saturation levels were documented, but the oxygen flow rate was not. Review of R44's Care Plan, initiated on 11/5/2024 and located in the EMR under the Care Plan tab, revealed the resident used oxygen and was at risk for respiratory distress due to a diagnosis of chronic obstructive pulmonary disease, and a history of respiratory failure. Interventions included maintaining the oxygen liters per minute as ordered by the physician, providing oxygen by nasal cannula or mask as ordered, and checking oxygen saturation as ordered and needed. During an observation on 6/23/2025 at 10:48 am, R44 was observed using oxygen from the room concentrator while in bed with his eyes closed. The oxygen concentrator was revealed to be set on 2 LPM (liters per minute). During an additional observation on 6/24/2025 at 9:30 am, R44 was again observed resting in bed while using the oxygen from the room concentrator. The oxygen concentrator was revealed to be set on 2 LPM. During an interview on 6/24/2025 at 9:32 am, Licensed Practical Nurse (LPN) 3 was asked to observe the LPM for R44. Prior to entering the resident's room, LPN3 stated that she believed the resident was supposed to be on 1 LPM of oxygen, but upon entering the resident's room, she observed R44 to be on 2 LPM. LPN3 stated that she thought R44 was the only resident at the facility who was supposed to be on 1 LPM of oxygen. Upon reviewing the physician's order for R44, she confirmed that the oxygen concentrator should have been set to 1 LPM. She stated that someone must have assumed the resident was on 2 LPM and had changed it to that setting. During an interview on 6/26/2025 at 10:05 am, the Assistant Director of Nursing (ADON) stated that the CNAs would monitor resident vitals for the nurses and would also let the nurses know if there was any resident change or difficulty in breathing. The ADON stated the CNAs would not adjust the LPM for the residents but would inform the nurse, who would then handle any concerns. During an interview on 6/26/2025 at 10:30 am, the Director of Nursing (DON) stated the CNAs could check the vitals, but the nurse was the only one who should check the resident's LPM to ensure it was on the right setting. She stated that she believed that the resident had adjusted her own LPM, but confirmed the nurses did not document the LPM in the EMR during medication administration to ensure the resident's oxygen rate was accurately set according to physician orders.

Based on staff interview, record review, and review of the facility's policy titled Abuse Investigation and Reporting, the facility failed to report an allegation of verbal abuse to the State Survey Agency (SSA) within two hours for two of three residents (R) (R18 and R40) reviewed for abuse out of a total sample of 37. Specifically, R6 verbally abused R18 and R40. Findings include: Review of the facility's policy titled Abuse Investigation and Reporting, dated 7/2017, indicated .All alleged violations involving abuse .will be reported to the facility Administrator.All alleged violations of abuse.will be reported immediately, but not later than.two (2) hours of if the alleged violation involves abuse. 1. Review of R6's admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE]. Review of R6's Behavioral Note, dated 12/12/2024 and located in the resident's EMR under the Prog (Progress) Note tab, indicated R6 verbally threatened R18 and R40, who were his roommates. During this situation, R6 told the staff he was the devil. 2. Review of R18's EMR titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. 3. Review of R40's EMR titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of a document provided by the facility titled Facility Incident dated 12/13/2024 indicated R6 verbally threatened his roommates with physical harm. Review of a document provided by the facility titled [Name of Police Department] Incident Report dated 12/13/2024 indicated the local police department was dispatched to the facility. Per the police report an officer arrived at the facility on this same date. The report indicated that facility staff reported R6 had verbally abused R18 and R40. The report indicated that both R18 and R40 did not report that anything was said to them by R6. The police wrote that R6 would not be charged. The report revealed that R6 had been moved to another room. Review of a document provided by the facility titled Facility Incident dated 12/13/24 indicated R6 verbally threatened his roommates with physical harm. In addition, R18 and R40 were interviewed and had no current fears from R6. Review of Record of In-service Training and Attendance Form dated 12/13/24 indicated an in-service was completed for Registered Nurse (RN)1 for her failure to report an allegation of abuse to the Administrator. During an interview on 06/24/25 at 8:18 AM, the Director of Nursing (DON) confirmed RN1 failed to report an allegation of abuse and therefore there was a delay in reporting to the State Survey Agency (SSA). The DON stated she and the Administrator were not aware until the next day, when they began to read the previous nursing notes. During an interview on 6/25/25 at 4:31 PM, the Administrator confirmed the resident-to-resident verbal abuse was not reported timely to the SSA. Cross-Reference F600

Based on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure two of 37 sampled residents (R) (R65 and R20) had an accurate Minimum Data Set (MDS) assessment. This deficient practice had the potential to place R65 and R20 at risk of inaccurate care plans and not receiving care according to their needs. Findings include: Review of the RAI Manual, dated 10/2024 and located at Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual | CMS, revealed .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. 1. Review of R65's admission Record located in the resident's electronic medical record (EMR) under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R65's Physical Therapy PT (Physical Therapy) Evaluation & Plan of Treatment, dated 12/2/2024 and provided by the facility, indicated R65 began skilled services. Review of R65's Physical Therapy PT Discharge Summary dated 12/30/2024 indicated R65 ended skilled therapy services. Review of R65's 5-day MDS, with an Assessment Reference Date (ARD) of 12/9/2024, located in the resident's EMR under the MDS tab, indicated that the resident had no physical therapy skilled services (minutes of therapy) identified during this assessment period. During an interview on 06/25/2025 at 2:53 pm, the Corporate MDS Coordinator (CMDSC) was provided with the opportunity to review R65's 5-day MDS and verified that there should have been skilled therapy minutes under PT in the assessment. During an interview on 6/26/2025 at 10:45 am, the CMDSC confirmed the skilled PT minutes were missed in the 5-day MDS assessment. 2. Review of R20's admission Record, found under the Profile tab of the electronic medical record, revealed R20 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, bipolar disorder, and anxiety disorder. Review of R20's Significant Change in status Minimum Data Set (MDS), with an assessment reference date (ARD) of 4/17/2024, located under the MDS tab of the EMR, revealed the Level II Pre-admission Screening and Resident Review (PASARR) condition of Serious Mental Illness (SMI) was checked. Review of R20's Annual MDS with an ARD of 4/18/2025, located under the MDS tab of the EMR, revealed the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? was marked No. Review of R20's Preadmission Screening Resident Review (PASRR II) dated 1/08/2025 and located in the resident's EMR under the Misc tab revealed Is there evidence of Serious Mental Illness (SMI)? Yes. During an interview on 6/24/2025 at 10:26 am, Licensed Practical Nurse (LPN) 4, who was the MDS Coordinator, stated, The annual MDS on 4/18/2025, PASRR II was not entered correctly, but was correct on the Significant Change MDS on 4/17/2024. It can be corrected. It should have been PASRR II for SMI. Normally, I look back at the previous annual MDS. During an interview on 6/26/2025 at 9:55 am, the DON stated, The expectation is that assessments are entered correctly and that interventions are keyed correctly and put into place. I am not that familiar with the MDS process.

Based on resident and staff interviews, record review, and review of the facility policy titled Falls and Fall Risk, Managing, the facility failed to conduct a thorough and accurate fall investigation for one of four residents (R) (R41) reviewed for falls. This failure had the potential to place R41 at risk of further falls. Findings include: Review of the facility's policy titled Falls and Fall Risk, Managing, dated 3/2018 indicated .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of R41's admission Record located in the resident's electronic medical records (EMR) under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review R41's 5-day MDS, with an ARD of 12/8/2024, indicated the resident had a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated the resident was moderately cognitively impaired. The assessment indicated no impairments bilaterally, both upper and lower extremities. The assessment revealed the resident required partial/moderate assistance for sitting to lying and from lying to sitting position. Review of R41's Care Plan, located in the resident's EMR under the Care Plan tab, dated 11/5/2024, indicated the resident had a history of frequent falls prior to admission and a diagnosis of frequent falls. There was no evidence in the care plan that addressed the use of bilateral side rails positioned in the center of the bedframe as a potential accident hazard. Review of R41's Fall Risk Evaluation located in the resident's EMR under the Assmnts [Assessment] tab dated 11/5/2025 revealed the resident scored 17 and was considered to be at risk for falls. Review of a document provided by the facility for R41 titled Investigation Follow-Up dated 1/2/2025 indicated the resident was found on the floor on the left side of his bed. The document indicated the resident stated he attempted to get out of bed and did not remember the reasons why. The resident sustained no injuries. There was no information regarding the placement of quarterly side rails attached to the center bed frame of the bed that may have impeded the resident's ability to exit his bed. During an observation on 6/23/2025 at 9:55 am, R41 was observed in bed. The resident had quarter bilateral side rails attached to the bed frame and engaged in the center of the bed. Observations on 6/23/2025 at 12:24 pm and 2:30 pm revealed that the quarter bilateral side rails were still placed in the center of the bed frame and engaged. During an interview on 6/24/2025 at 11:26 am, R41 stated he attempted to get out of bed, and he crawled to the bottom of the bed to get out of the bed. During an interview on 6/24/25 at 10:59 am, the Director of Nursing (DON) stated that the side rails for R41 were not reviewed as a potential accident hazard for R41. The DON stated her concerns were a potential accident hazard if the resident attempted to climb over the side rails.

Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure adequate interventions were provided to establish proper nutrition for gradual weight loss for one of six residents (R) (R38) reviewed for nutrition. This placed the resident at risk for further weight loss. Findings include: Review of a facility policy titled Nutrition, dated 4/29/2019 indicated .Each resident will maintain acceptable parameters of nutritional status, such as body weight.unless the resident's condition reflects that this is not possible. There was no information in the facility policy that addressed gradual weight loss. Review of R38's admission Record located in the resident's electronic medical record (EMR) under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R38's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 4/17/2025 indicated the resident had a Brief Interview for Mental Status (BIMS) score of nine out of 15, which revealed the resident was moderately cognitively impaired. The assessment indicated the resident required either supervision or touch during eating. The assessment revealed the resident had no weight loss of five percent or more in the last month or loss of 10 percent or more within the last six months. Review of R38's Nutrition/Dietary Note located in the resident's EMR under the Prog (Progress) Note tab dated 1/31/2025 indicated the Registered Dietitian (RD) assessed the resident's nutrition and determined the resident was eating 40 to 65 percent of his meals on average. Review of R38's Weight Summary located in the resident's EMR under the Wts [Weights]/Vitals tab indicated the following weights: on 1/20/2025 the resident weighed 193 pounds; on 1/24/2025 the resident weighed 189 pounds; on 2/20/2025 the resident weighed 187 pounds; on 3/6/2025 the resident weighed 195 pounds; on 4/2/2025 the resident weighed 186 pounds; on 5/2/2025 the resident weighed 181 pounds; and, on 6/10/2025 the resident weighed 175 pounds. From 1/20/2025 to 6/10/2025, R38 sustained a 9.33 percent weight loss. From 4/2/2025 to 6/10/2025, R38 sustained 6.29 percent weight loss. Review of R38's PAR (Patient at Risk) notes located in the resident's EMR under the Prog Note tab dated 6/11/2025 that the resident was placed on PAR due to a trigger of 10.26 percent weight loss in three months and a 12.6 percent weight loss in six months. The progress notes indicated the resident's weight was 173 pounds. The progress notes revealed the resident could feed himself but was non-compliant with the nutritional supplement ordered. Review of R38's Documentation Survey Report for the month of 4/2025 located in the resident's EMR under the Reports tab failed to indicate documented evidence of what the resident consumed on the following dates: on 4/1/2025 there was no documentation for breakfast and lunch meals; on 4/2/2025 there was no documentation for the lunch meal; on 4/4/2025 there was no documentation for the breakfast and lunch meals; on 4/9/2025 and 4/10/2025 there was no documentation for the breakfast and lunch meals; on 4/14/2025 and 4/15/2025 there was no documentation for the dinner meals; on 4/17/2025 and 4/18/2025 there was no documentation for the breakfast and lunch meals; from 4/21/2025 to 4/25/2025 there was no documentation for the breakfast and lunch meals; and on 4/30/2025 there was no documentation for the breakfast and lunch meals. Review of R38's Documentation Survey Report for the month of 5/2025 located in the resident's EMR under the Reports tab failed to indicate documented evidence of what the resident consumed on the following dates: on 5/1/2025 and 5/2/2025 there was no documentation for the breakfast and lunch meals and in addition there was no documentation for the dinner meal on 5/1/2025; on 5/5/2025 through 5/9/2025 there was no documentation for the breakfast and lunch meals, in addition there was no documentation on 5/5/2025, 5/6/2025, and 5/8/2025 for the dinner meals; on 5/13/2025 through 5/16/2025 there was no documentation for the breakfast, lunch, and dinner meals; on 5/19/2025 and 5/20/2025 there was no documentation for the breakfast and lunch meals; on 5/26/2025 there was no documentation for the breakfast, lunch and dinner meals; and on 5/20/2025 there was no documentation for the breakfast and lunch meals. Review of R38's Documentation Survey Report for the month of 6/2025 located in the resident's EMR under the Reports tab failed to indicate documented evidence of what the resident consumed on the following dates: on 6/2/2025 there was no documentation for the dinner meal; on 6/3/2025 there was no documentation for the breakfast and lunch meals; and on 6/4/2025 through 6/6/2025 there was no documentation for the breakfast, lunch, and dinner meals. Review of R38's Resident PAR Listing dated 6/11/2025 indicated the RD was in attendance. There was no documentation that the RD made any recommendations for R38 during this meeting. Review of R38's PAR located in the resident's EMR under the Prog Note dated 6/18/2025 indicated the resident continued to lose weight, and at the time of this entry, the resident weighed 170, which was three pounds less than a week prior. Again, the progress note indicated the resident was non-compliant with the nutritional supplement ordered. During an observation on 6/23/2025 at 12:49 pm, R38 was served his lunch meal at the bedside. The observation ended at 1:00 PM, and the resident did not touch his meal. During an interview on 6/25/2025 at 3:19 pm, the RD stated he came to the facility once a month, and part of his responsibilities were to document the higher-risk weight loss patients. The RD stated he did not address residents with gradual weight loss and only focused on the 30-day and 6-month MDS assessments. The RD stated he was unaware if he had watched R38 eat a meal or not. During an interview on 6/26/2025 at 11:10 am, the Director of Nursing (DON) stated that if a resident had gradual weight loss, the facility would look at a possible diagnosis, mental capacity, and then make some recommendations. The DON stated her expectations would be that the RD address gradual weight loss in a resident and look at recommendations.

Based on staff interviews, record review, and review of the facility's policy titled Abuse, Neglect and Exploitation, the facility failed to protect three residents (R) (R62, R18, and R40) of four residents reviewed for abuse were free from physical or verbal abuse out of 37 total sampled residents. Specifically, R62 was physically abused by R6, and R18 and R40 were verbally threatened by R6. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 2017, indicated .Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. 1. Review of R6's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R6's EMR titled Care Plan located under the Care Plan tab dated 11/13/2024 indicated the resident had behaviors of yelling, striking out, and attempting to strike out other residents and staff. Review of R6's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/04/2024 and located in the resident's EMR under the MDS tab, indicated the resident had a Brief Interview for Mental Status (BIMS) score of eight out of 15, which revealed the resident was moderately cognitively impaired. The assessment indicated the resident had physical and verbal threats against others during this assessment period. The assessment revealed the resident was dependent on staff to transfer him from bed to his wheelchair. Review of R6's Behavioral Note located in the resident's EMR under the Prog (Progress) Note tab dated 11/13/2024 indicated R6 was sitting on the outside of his room when R62 walked up to the resident and bent down to speak with R6. R6 then slapped R62 across the face. Review of R6's Care Plan, located in the resident's EMR under the Care Plan tab, dated 11/13/2024, indicated that the resident had a history of hitting, yelling, and attempting to strike out at both staff and other residents. The care plan was reviewed on 4/3/2025, in which the resident was identified with adverse behaviors related to the diagnosis of schizophrenia and intellectual disabilities. The care plan identified that the resident had a history of lashing out and refusing care. Review of R6's Behavior Note located in the resident's EMR under the Prog Note tab dated 12/12/2024 indicated the resident was verbally abusive towards staff and his roommate. R6 threatened to choke R18 and R40. On 12/13/2024, R6 became more verbally abusive towards staff and police, and emergency medical services were notified. R6 was taken to the local emergency room. During an interview on 6/23/2025 at 10:04 am, R6 denied hitting any of the staff. 2. Review of R62's EMR titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R62's Annual MDS, with an ARD dated 9/7/2024 located in the resident's EMR under the MDS tab, indicated the resident had a BIMS score of five out of 15, which revealed the resident was severely cognitively impaired. The assessment indicated the resident used a walker for ambulation. Review of R62's PAR (Patient at Risk) progress notes, dated 11/13/24, and located in the resident's EMR under the Prog Note tab, indicated the resident was stable at baseline. An attempt was made to interview R62 on 6/24/2025 at 1:22 pm, and she was unable to respond to questions. A review of a document provided by the facility titled Facility Incident, dated 11/13/2024, indicated R6 was sitting in the hallway when R62 approached R6, leaned over, and then R6 slapped R62 on her face and nose. R62 was removed from the situation and assessed and had no injuries. Certified Nurse Aide (CNA) 2 observed the resident-to-resident. CNA2 confirmed the resident-to-resident incident. CNA2 attempted to separate the two residents, but before the staff member could, the resident-to-resident happened. The physician was notified of the resident-to-resident incident and ordered a medication change for R6. R62 was placed on visual checks every 30 minutes. On 11/14/2024, R6 became highly disrupted and began throwing items at staff. The physician was notified and ordered Haldol 5 milligrams (mg) intramuscular and directed the staff if the resident did not improve to send him to the local emergency room for evaluation and treatment. R6 began to escalate again. The police were called and escorted R6 to the local emergency room. The investigation showed that the State Survey Agency (SSA) was notified, and a five-day report was submitted timely. As part of the facility investigation, other residents and staff were interviewed, and there were no issues identified. Finally, R6 returned back to the facility and was identified with a urinary tract infection and was placed on antibiotics. During an interview on 6/24/2025 at 1:05 pm, CNA 2 verified he was the staff member who observed the resident-to-resident which involved R6 and R62, and confirmed R6 slapped R62 and he considered the incident abuse. 3. Review of R18's EMR titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R18's Quarterly MDS, with an ARD of 12/03/24 and located in the resident's EMR under the MDS tab, indicated the resident had a BIMS score of two out of 15, which revealed the resident was severely cognitively impaired. During an interview on 6/24/2025 at 7:30 am R18 stated he was not afraid of R6. 4. Review of R40's EMR titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R40's Quarterly MDS, with an ARD of 9/13/2024, located in the resident's EMR under the MDS tab, indicated the resident had a BIMS score of eight out of 15, which revealed the resident was moderately cognitively impaired. During an interview on 6/25/2025 at 9:08 am, R40 stated he remembered R6 but did not remember being yelled at by him, nor was he afraid of R6. Review of a document provided by the facility titled Facility Incident, dated 12/13/2024, indicated R6 verbally threatened his roommates with physical harm. Staff attempted to redirect and offer a blanket to cover his head without success. R6 complained of bed and was given pain medication, and there were no further incidents. Staff initiated one-hour checks on R6 during this time. On 12/13/2024, R6 became verbally and physically aggressive with staff. Per the facility investigation, staff attempted to redirect R6, and this was unsuccessful. R6's physician was notified and ordered to send the resident to the local emergency room. The police were contacted as well. Interviews were collected from R18. R18 did not respond to questions, and R40 stated R6 yelled quite a bit and ignored R6's outbursts. Both R18 and R40 were seen by mental health on 12/13/2024, and there were no recommendations. During an interview on 6/25/2025 at 4:31 pm, the Administrator stated the facility did not take allegations of abuse lightly. The Administrator stated that there had been no further outbursts directed at the residents by R6. The Administrator stated that behavioral health was in the building on a weekly basis, and the staff could make referrals directly to the behavioral health professional when behaviors occur.

Based on observations, staff interviews, and review of the facility policy titled, Dignity, the facility failed to ensure 34 of 81 residents' meals were served on dinner ware instead of disposable Styrofoam food containers and hydration in disposable cups. The deficient practice had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each residents' quality of life.Review of the facility policy titled, Dignity, with the revised date of February 2021, revealed under Policy Interpretation and Implementation number 5e. provided with a dignified dining experience.Observation on 8/12/2025 at 10:30 am revealed there were 47 eight-inch round plastic re-usable plates on warmers stacked on top of a cart next to the steam table as well as a stack of disposable black Styrofoam hinged-lid food containers. During an interview on 8/12/2025 at 10:30 am, Dietary [NAME] 4 (DC4) confirmed that these were the only re-usable plates in the facility to serve 81 residents. During the interview DC5 revealed that there were not enough plates in the facility and disposable containers had to be used and the dietary staff had been using the disposable plates and cups for over a month. During an interview on 8/12/2025 at 4:00 pm, the Dietary Manager (DM) confirmed residents' meals were served in disposable Styrofoam food containers and drinking cups, for about a month. The DM did not provide a clear explanation for why disposable dishware was being used.During an interview on 8/13/2025 at 2:00 pm, with the Administrator revealed that staff is expected to serve the residents meals on re-usable dinnerware and notify her when additional plates and drinking glasses need to be ordered.

Based on observations, staff interviews, and review of the facility's policy titled Administering Medications, the facility failed to ensure infection control was maintained for one of three residents (R) (R68) observed during medication administration. Specifically, the facility failed to ensure medications were not touched with bare hands or dropped during medication administration, which increased the risk for cross-contamination and infection. Findings include: Review of the facility's policy titled Administering Medications, dated 4/1/2019, included, Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. During observation and interview on 6/25/2025 at 9:23 am of medication administration with Licensed Practical Nurse (LPN) 3, the LPN opened multiple pill packs of medications for R68 and poured them into the pill cup. Two of the pills dropped on top of the medication cart. LPN3 picked up the unknown pills with her bare hand and placed them back into the pill cup with the other pills. LPN3 confirmed she picked up the pills with her bare hand and placed them in the pill cup with other pills and stated, I didn't think about it. I should have used a glove to pick up the pills. LPN3 then administered the medications to R68. During an interview on 6/26/2025 9:42 am, the Director of Nursing (DON) stated, The expectation is for the nurse to use a glove to pick up pills if dropped on top of a clean medication cart and definitely discarded if the surface is not clean or if dropped on the floor. Then, pull the medications from the back of the box and contact the pharmacy to replace the medication.

Based on observations, resident and staff interviews, record review, recipe review, and review of the facility's policies titled Standardized Recipes and Preparing Pureed Foods, the facility failed to ensure recipes were followed to ensure the food was palatable for four of 37 sampled residents (R) (R60, R56, R45, and R25). This failure had the potential to place R60, R56, R45, and R25 at risk of decreased oral intake and weight loss. Findings include: Review of the facility's policy titled Standardized Recipes, dated 3/2025, revealed 1. Recipes contain the following: a. Ingredients and amounts required for the recipe. b. Preparation method. c. Other preparation information .2. Dietary Manager will provide recipes for the foods to be prepared. Review of the facility's policy titled, Preparing Pureed Foods, dated 3/2025, revealed 1. Prepare food following the recipe for the regular texture foods. Pureed food should have the same flavor as their regular texture counterpart. 2. Specific pureed recipes included in the menu system may be used. 3. If the specific pureed recipe is not utilized, the following may be used .c. If the texture of the pureed food is not at the correct consistency, add a liquid such as broth, juice, tomato juice or milk. Do not add water .d. Do not use water during the pureeing process. 1. Review of R60's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/13/2025, and located in the MDS tab of the electronic medical record (EMR), revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated the resident was moderately cognitively impaired. Review of the undated Diet Type Report located under the Reports tab of the EMR for R60 revealed Diet Type: NAS [No Added Salt] Mechanical Soft with Ground Meat. During an interview on 6/23/2025 at 10:05 am, R60 stated the food was horrible. She stated that she was supposed to get pureed vegetables, but they did not taste good. She stated the food was not appealing, so she did not want to eat it. She further stated that she bought her own food from the store a lot. 2. Review of R56's five-day MDS with an ARD of 5/9/2025, and located in the MDS tab of the EMR, revealed a BIMS score of 12 out of 15, which indicated the resident was moderately cognitively impaired. Review of the undated Diet Type Report located under the Reports tab of the EMR for R56 revealed Diet Type: Low Concentrated Sweets. Regular. During an interview on 6/23/2025 at 1:20 pm, R56 stated the food was pig slop, the way it was prepared with overcooked meat and gravy. 3. Review of R45's Significant Change MDS with an ARD of 5/13/2025 and located in the MDS tab of the EMR, revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of the undated Diet Type Report located under the Reports tab of the EMR for R45 revealed Diet Type: NAS. Regular. During an interview on 6/23/2025 at 1:40 pm, R45 stated the food had been poor over the past few weeks. He stated the food on this day had no flavor. 4. Review of R25's Quarterly MDS with an ARD of 5/17/2025 revealed a BIMS score of 10 out of 15, which indicated the resident was moderately cognitively impaired. Review of the undated Diet Type Report located under the Reports tab of the EMR for R25 revealed Diet Type: Pureed with Nectar Thick fluid consistency. During an interview on 6/25/2025 at 4:45 pm, R25 stated she ate yogurt for lunch. She stated she tried the ham, but it was not good. She stated she did not eat any other food. Review of the Resident Council notes, provided by the facility and dated May 27, 2025, revealed that R19 stated, The food was either overcooked or undercooked. Review of the Resident Council's notes with R5, R23, R53, R55, and R61 in attendance, provided by the facility and dated 6/9/2025, revealed Need to improve the quality of food. Review of the undated recipe titled Brown Sugar Glazed Ham, provided by the facility, revealed to remove ham from the oven about 30 minutes before it is done. Drain off drippings. [NAME] sugar glaze: light brown sugar, ground spice mustard, and white distilled vinegar. Combine ingredients for glaze. Spoon over ham. Repeat if a heavier glaze is desired. Return ham to oven and bake at 350 degrees F [Fahrenheit] for 40 minutes. Review of the undated recipe titled Yams, provided by the facility, revealed canned cut yams, drain potatoes, and heat until internal temperature reaches 135 degrees F. No additional ingredients were listed. Review of the undated recipe titled Buttered Beets, provided by the facility, revealed canned, sliced beets. Heat beets. Drain. Add margarine and pepper. Toss lightly to mix. During an observation and interview on 6/25/2025 at 11:21 am, Cook3 placed two blocks of butter on the counter. At 11:25 am, a container of cinnamon and a container of allspice were placed on the counter. At 11:28 am, [NAME] 1 placed butter, cinnamon, and allspice in a pan on the stove. [NAME] 3 took the yams out of the oven and began mixing the mashed yams and visible butter. [NAME] 3 stated she added butter, cinnamon, and brown sugar to the mashed yams. At 11:36 am, Cook3 placed the brown sugar into the butter and seasoning mixture in the pan on the stove. At 11:58 am, she stated she had added butter to the beets and stated that was the only way to eat them. The beets were not drained. During an observation on 6/25/2025 at 12:04 pm, Cook3 prepared pureed ham by placing ham pieces into the blender and adding water to the ham. At 12:08 pm and 12:16 pm, she added more water to the ham. At 12:17 pm, she placed the pureed ham into a pan and placed it on the steam table without ensuring proper temperature. At 12:26 pm, she prepared the pureed bread with water. At 12:36 pm, she prepared the pureed beets with water and placed them on the steam table without ensuring proper temperature. On 6/25/2025 at 12:38 pm, a test tray was plated from the tray line. The test tray was evaluated at 12:40 pm with the Dietary Manager (DM). The test tray had two meals. One meal had pureed ham with sauce poured on top, pureed yams, and pureed beets. The other meal had a slice of ham without sauce, mashed yams, and beets. The DM stated the pureed ham was a little salty. She stated she tasted some cinnamon, but mostly salt. She stated the regular textured mashed yams tasted bland. She further stated that the regular-textured beets tasted like beets, but they needed seasoning. She stated they were supposed to be buttered beets, but she did not taste the butter. The DM stated the dietary staff had recipes, and they were probably on her desk. During an interview on 6/25/2025 at 3:12 pm, the DM stated the dietary department did not have any pureed recipes, as far as she was aware. During an interview on 6/25/2025 at 3:25 pm, the Registered Dietitian (RD) stated he worked at the facility once a month, and he looked around the kitchen. He stated that he had spoken to the DM and reviewed the basics with her. He stated he completed kitchen walkthroughs but had not completed any test trays as long as the DM had been the manager. He further stated he had not completed any education or training with dietary staff, only the DM. He stated that there were puree recipes in the menu system. During an interview with the Administrator, the Regional Administrator, and the DM on 6/26/2025 at 8:57 am, the Regional Administrator stated that there should be a recipe for everything. The DM stated the expectation was for dietary staff to follow the recipes.

Based on observation, staff interview, review of manufacturer package insert, and review of the facility policies titled Medication Storage in the Facility and Administering Medications, the facility failed to discard an expired insulin vial for one of three medication carts and failed to monitor the temperatures of one of one medication storage refrigerators. The deficient practice could result in decreased or altered effectiveness of the medication and worsening of the resident's symptoms. Findings include: Review of the facility's policy titled Medication Storage in the Facility, dated [DATE], revealed Medications requiring refrigeration or temperatures between 36 degrees and 46 degrees Fahrenheit (F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Review of the facility's policy titled Administering Medications, revised on [DATE], revealed The expiration/beyond use date on the medication label is checked prior to administering. Review of the Novolog package insert titled Highlights of Prescribing Information, revised 2/2023, and provided by the facility revealed Throw away all opened Novolog vials after 28 days, even if they still have insulin left in them. 1. Observation and interview on [DATE] at 3:18 pm of the nurse's medication cart with Licensed Practical Nurse (LPN) 1 on the B Hall revealed a Novolog (insulin) vial for resident (R) 41 had an open date of [DATE] and was to be discarded within 28 days after the date opened. LPN1 stated the insulin vial was expired and should have been discarded within 28 days of the open date. Review of R41's admission Record, found under the Profile tab of the electronic medical record (EMR), revealed R41 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus with hyperglycemia. Review of R41's Medication Administration Record (MAR), dated [DATE] to [DATE] found under the Orders tab of the EMR, revealed a physician's order dated [DATE] for Novolog Injection solution (insulin) 100 units per milliliter, inject per sliding scale. subcutaneously four times a day . Review of R41's Minimum Data Sheet (MDS), with an assessment reference date (ARD) of [DATE], found under the MDS tab of the EMR, revealed the resident received insulin injections. Review of R41's Care Plan dated [DATE], found under the Care Plan tab of the EMR, revealed the resident had diabetes mellitus that required insulin. During an interview on [DATE] at 9:48 am, the Director of Nursing (DON) stated the expectation was for nurses to check the open date of insulin vials prior to administering insulin and not give expired insulin. The DON stated that an adverse action of expired insulin could be decreased effectiveness, and blood sugars could go up, and the resident could end up with a hospital visit. 2. An observation on [DATE] at 4:00 pm, of the medication storage room with Licensed Practical Nurse (LPN) 3 revealed the medication refrigerator temperature log located on the front of the refrigerator had missed temperature checks on [DATE] and [DATE]. The refrigerator stored the facility's refrigerated medications, including influenza and pneumonia vaccines. During an interview on [DATE] at 4:17 pm, the Director of Nursing (DON) stated that [DATE] and [DATE] were weekend days and the weekend supervisor was responsible for monitoring and documenting the medication refrigerator temperatures daily. The DON stated, If the temperature was out of range, the vaccinations would not be good anymore.

Based on record review, staff interviews, and review of the facility's policies titled Administering Medications and Hypertension- Clinical Protocol, the facility failed to ensure two of five residents (R) (R23 and R35) reviewed for unnecessary medications were free from significant medication errors. Specifically, when R23 did not receive glargine (insulin medication) on four occasions, Novolog (insulin medication) on five occasions, and hydralazine (blood pressure medication) on three occasions, and when blood pressure medication was not held according to the physician's order for a low blood pressure for R35. These failures had the potential to place R23 and R35 at risk for medical complications and a diminished quality of life. Findings include: Review of the facility's policy titled Administering Medications, revised 4/1/2019, provided by the facility, revealed Medications are administered in accordance with prescriber orders . Review of the facility's policy titled, Hypertension- Clinical Protocol, revised 11/2018, revealed Overtreating blood pressure may increase the risk of significant side effects and complications . 1. Review of R23's admission Record located in the Profile tab of the electronic medical record (EMR) revealed R23 was admitted to the facility on [DATE] with diagnoses, which included diabetes mellitus and hypertension. Review of R23's Physician Orders located under the Orders tab of the EMR, revealed R23 was to receive an order dated 3/18/2025 for insulin glargine solution 100 unit per milliliter (ml) inject 12 unit subcutaneously two times a day for diabetes; NovoLog injection solution 100 unit/ml (insulin aspart) inject as per sliding scale subcutaneously before meals and at bedtime related to Type 2 diabetes mellitus with hyperglycemia; and hydralazine hydrochloride oral tablet 50 mg give one tablet by mouth every eight hours related to hypertensive heart disease with heart failure hold for systolic blood pressure less than 110, dated 12/4/2024. Review of R23's Medication Administration Record (MAR), dated 6/1/2025 through 6/30/2025, located under the Orders tab of the EMR, revealed no documentation that R23 had received insulin glargine as ordered on 6/6/2025, 6/17/2025, 6/20/2025, and 6/21/2025. There was no documentation that R23 had blood sugars checked, and NovoLog injection solution was received as ordered on 6/6/2025, 6/17/2025, 6/19/2025, 6/20/2025, and 6/21/2025. There was no documentation that hydralazine was administered as ordered on 6/6/2025, 6/19/2025, and 6/23/2025, and no record of a blood pressure check on 6/23/2025. During an interview on 6/26/2025 at 10:02 am, the Director of Nursing (DON) reviewed R23's clinical record and confirmed there was no documentation regarding the administration of the above medications. The DON stated that if it's not documented, we cannot prove that the medication was administered. The DON stated it was her expectation that medications were checked off once administered and that blood sugars and blood pressure would have been documented. The DON stated these medications were considered significant medications and significant medication errors. The adverse consequences of these medications not being administered as ordered have caused increased blood sugars and an increase in blood pressure. 2. Review of R35's undated admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE]. Diagnoses included pulmonary hypertension and hypertensive heart disease without heart failure. Review of R35's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/5/2025 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) of eight out of 15, which indicated R35 had moderately impaired cognition. Review of R35's Medication Administration Record (MAR), dated 6/2025 and located under the Orders tab of the EMR, revealed the resident was ordered to receive metoprolol tartrate oral tablet 50 mg (milligram). Give one tablet by mouth every 12 hours related to hypertensive heart disease without heart failure. Hold for systolic blood pressure (SBP) of less than 100 .start date 4/28/2025. The medication was marked as given on 6/16/2025 at 9:00 am with a blood pressure of 94/57 and on 6/17/2025 at 9:00 am with a blood pressure of 94/57. During an interview on 6/24/2025 at 8:33 am, the DON stated the medication was checked off in the EMR as given. She confirmed the medication should have been held according to the physician's orders for the blood pressure parameters.

Based on observations, staff interviews, record review, and review of the facility policy titled Bed Safety and Bed Rails, the facility failed to ensure three of 37 sampled residents (R) (R78, R38, and R41) were appropriate for the use of quarter side rails on their beds. This failure had the potential to place R38 and R41 at risk for injury related to potentially unnecessary side rail use. Findings include: Review of the facility policy titled Bed Safety and Bed Rails, dated 2001, indicated . Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met.prior to the instillation or use of a side or bed rail, alternatives to use of side or bed rails are attempted. Alternatives may include. roll guard. foam bumpers. lowering the bed. use of a concave mattress to reduce rolling off the bed.If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails.The interdisciplinary evaluation includes.An evaluation of the alternatives to be rails that were attempted and how these alternatives failed to meet the resident's needs.the resident's risk associated with the use of bed rails.input from the resident and/or representative.consultation with the attending physician.The resident assessment also determines potential risks to the resident associated with the use of bed rails.including the following.The resident could attempt to climb over, around, between, or through the rails. 1. Review of R78's admission Record located in the resident's electronic medical record (EMR) under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review R78's Bed Rail Assessment, dated 5/20/2025, and located in the resident's EMR under the Assessment tab, indicated R78 was assessed for the use of side rails at the time of her admission. Review of R78's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/27/2025 located in the resident's electronic medical record (EMR) under the MDS tab indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which revealed the resident was moderately cognitively impaired. The assessment revealed the resident sustained a fall, with no injuries, during this assessment period. Review of R78's Care Plan located in the resident's EMR under the Care Plan tab dated 6/3/2025 indicated the resident was placed on a falling star program. There was no evidence to indicate the resident used the side rails for a positioning aide. During an observation on 6/23/2025 at 10:15 am, R78 was in bed with bilateral one-quarter side rails engaged. The bilateral side rails were positioned on the top half of the resident's bed. During this observation, the resident stated she had fallen from bed when she scooted down to the edge of the bed in an attempt to get up to use the bathroom. During an observation and interview on 6/24/2025 at 6:35 am, the Director of Nursing (DON) confirmed the bilateral side rails were engaged on R78's bed. The DON stated the resident does attempt to get up without staff assistance. 2. Review of R38's admission Record located in the resident's EMR under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R38's Red Rail Assessment, dated 3/12/2024 and located in the resident's EMR under the Assessments tab, indicated R38 was assessed for the use of side rails on the date of the resident's admission. Review of R38's annual MDS, with an ARD of 4/17/2025 and located in the resident's EMR under the MDS tab, indicated the resident had a BIMS score of nine out of 15, which revealed the resident was moderately cognitively impaired. The assessment revealed the resident sustained no falls during this assessment period. Under the Care Area Assessment (CAA), the resident triggered for falls and directed the staff to develop a care plan. Review of R38's Care Plan located in the resident's EMR under the Care Plan tab dated 1/16/2025 indicated the resident was at risk for falls. There was no evidence to indicate the resident used the side rails for a positioning aide. During an observation on 6/23/2025 at 12:50 pm, R38 was observed with bilateral one-quarter side rails positioned in the center of the mattress attached to the bed frame. 3. Review of R41's admission Record located in the resident's EMR under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R41's Care Plan, located in the resident's EMR under the Care Plan tab, dated 11/5/2024 revealed the resident had a history of falls prior to his admission and a diagnosis of difficulty walking. Review R41's Bed Rail Assessment, dated 11/5/2024 and provided by the facility, indicated R41 was assessed for the use of side rails on the day of his admission. Review of R41's 5-day MDS, with an ARD of 12/8/2024 located in the resident's EMR under the MDS tab, indicated the resident had a BIMS score of nine out of 15, which revealed the resident was moderately cognitively impaired. The assessment revealed the resident had no falls during this assessment period. During an observation on 6/23/2025 at 9:55 am, R41 was observed in bed with bilateral quarter side rails engaged, positioned in the center of the mattress attached to the bed frame. During an interview on 6/24/2025 at 10:16 am, the Director of Rehabilitation (DOR) stated that all residents, upon admission, were assessed for the use of side rails to determine if the side rails were appropriate or not. The DOR stated she would then notify the Maintenance Director for installation. The DOR stated therapy would not recommend any other alternatives for bed mobility until the resident completed skilled therapies. Observation on 6/24/2025 at 10:31 am with the DOR of R38's room revealed the bilateral side rails were not engaged, since the resident was not in his room. During an observation on 6/24/2025 at 10:33 am with the DOR of R78's room, the DOR verified that the bilateral side rails were engaged on her bed. During an observation on 6/24/2025 at 10:33 am with the DOR of R41's room, the DOR verified the bilateral side rails, which were centered in the middle of the bed frame, were engaged. During an interview on June 25, 2025, at 4:31 p.m., the Administrator stated that it was her understanding that a therapy assessment would be completed for the use of side rails to determine their appropriateness. She was unable to provide evidence on any alternatives prior to the use of side rails for the three residents.

Based on observation, staff interviews, and review of the facility's policies titled, ''Date Marking for Food Safety'' and ''Food Safety Requirements,'' the facility failed to date, label, and/or cover food, and discard food with expired expiration dates or signs of spoilage stored in the facility's kitchen and the facility's ''Diet Room.'' Additionally, the facility failed to serve [NAME] stew from the kitchen's tray line at an internal temperature of 135 degrees Fahrenheit (F) or higher. This failure had the potential to affect all 67 residents who consumed food prepared from the facility's kitchen. Findings include: Review of the facility's undated policy titled, ''Date Marking for Food Safety,'' indicated, ''Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for food safety . 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared . 6. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 7. The Dietary Manager (DM), or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed.'' Review of the facility's undated policy titled, ''Food Safety Requirements,'' indicated, ''Policy: . Food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety . Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded . Ready-to-eat foods that require heating before consumption must be heated to at least 135 [degrees] F.'' 1. Observation during the initial kitchen inspection on [DATE] from 9:35 am to 10:15 am, revealed the following concerns with food storage: a. Observation of food stored in the kitchen's walk-in refrigerator revealed a five pound container of Ricotta cheese with an expired expiration date of [DATE], three stalks of wilted and brownish colored celery, 28 undated and unlabeled plastic cups of leftover fruit with whipped topping, an opened and undated package of Swiss cheese, an opened and undated package of provolone cheese slices, an undated and unlabeled large container of leftover cooked macaroni, an undated and unlabeled large container of leftover tomato soup, an undated and unlabeled large container of jelly, two undated thawed four-ounce nutritional shakes, and two undated and unlabeled opened loaves of marble rye bread. b. Observation of food stored in the kitchen's reach-in refrigerator revealed an undated and unlabeled package of American cheese, an undated thawed four-ounce nutritional shake, two undated and unlabeled opened loaves of bread, eight undated and unlabeled plastic cups of leftover vanilla pudding. c. Observation of food stored in the kitchen's reach in freezer revealed an opened, undated, and uncovered large bag of carrot coins; and an opened, undated, and uncovered 18.75-pound box of wheat rolls. d. Observation of food stored in the kitchen's chest freezer revealed an opened, undated, and uncovered large bag of chicken nuggets. e. Observation of food stored in the kitchen's dry storage area revealed an opened and uncovered 25-pound bag of brown rice. During an interview on [DATE] at 10:15 am, the Dietary Manager (DM) confirmed the undated, unlabeled, uncovered, expired, and spoiled food observed stored in the kitchen's walk-in refrigerator, reach-in refrigerator, reach-in freezer, chest freezer, and dry storage area. The DM stated staff were expected to date, label, and completely cover opened foods prior to storing them and to discard any food with an expired expiration date or signs of spoilage. 2. Observation of food stored in the facility's ''Diet Room'' refrigerator on [DATE] at 2:45 pm, revealed eight undated thawed four-ounce nutritional shakes, and two undated plastic cups of pudding. During an interview on [DATE] at 2:50 pm, the DM confirmed the eight thawed nutritional shakes, and the two containers of pudding stored in the Diet Room's refrigerator were not dated. The DM stated the eight thawed nutritional shakes, and two containers of pudding should have been dated by staff before they left the kitchen. 3. Observation on [DATE] at 12:05 pm of kitchen staff preparing resident lunch meal trays from the kitchen's tray line revealed Cook (C) 1 was placing a pre-poured bowl of [NAME] stew on resident trays. Upon request, the DM monitored the temperature of a pre-poured bowl of [NAME] stew that was on the tray line, with a calibrated thermometer, and the internal temperature of the stew was measured at 123.8 degrees F. During an interview on [DATE] at 12:05 pm, the DM stated the temperature of the [NAME] stew was monitored about a half hour before the lunch tray line began and at that time the internal temperature of the stew was 157 degrees F which was documented on the kitchen's ''Food Temperature Log.'' The DM stated no further temperature monitoring of the [NAME] stew was performed before it was served from the tray line. The DM confirmed the [NAME] stew needed to be maintained at a temperature of 135 degrees F or above when served from the kitchen's tray line.

Based on record review, interviews, and policy review, the facility failed to ensure that one resident (R) (R#41) was free from significant medication error. Actual harm occurred when insulin and medications with sedative effects were administered to R#41, who was lethargic and difficult to arouse, resulting in emergency room visit and treatment with [MEDICATION(S)] for unresponsiveness and opioid overdose. The sample size was 31. Findings include: Review of the undated policy titled Medication Incidents and Adverse Reactions revealed 1. In the event of a medication discrepancy, medication error, or adverse medication reaction, immediate action is taken, as necessary, to protect the patient's safety and welfare. 2. Report the incident immediately to the director of nursing or acting supervisor. 3. The attending physician is notified promptly of the error or significant adverse medication reaction. 9. Significant medication errors and significant adverse drug reactions are defined as unintended, undesirable, and unexpected effects of prescribed medications. Significant medication errors require initial or prolonged hospitalization and require treatment with another prescription medication. Review of the clinical record revealed R#41 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 12, indicating moderate cognitive impairment. Section N revealed R#41 received insulin injections, antianxiety and opioid medications, seven of seven days. Review of R#41's September 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] [insulin] 100 unit/ml (Milliliter) vial give 15 units subcutaneously (subq) before meals. Hold if NPO [nothing by mouth] or not eating, order date 4/28/22. -[MEDICATION(S)] [insulin] 100 unit/ml give 30 units subq twice daily, order date 4/28/22. -[MEDICATION(S)] [muscle relaxant] 20 mg [milligram] tablet, one tablet by mouth every six hours, order date 2/6/18. -[MEDICATION(S)] [nerve pain medication] 150 mg capsule take one capsule by mouth every six hours scheduled, order date 4/25/22. -[MEDICATION(S)] [narcotic] HCL [[MEDICATION(S)]] 20 mg tablet, one tablet by mouth every 6 hours, order date 4/5/2020. -[MEDICATION(S)] [sedative] 0.5 mg tablet give one tablet by mouth twice a day, order date 3/8/22. Review of the September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Progress Note, written by Licensed Practical Nurse (LPN) C, dated 9/6/22 at 8:29 a.m. revealed resident was unable to arouse enough to wake and eat breakfast, tried several times, VSS [vital sign stable]. Further review of the Progress Notes revealed no evidence that the physician was notified that R#41 had a change in condition and that staff was unable to arouse her. Review of the September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Progress Notes, written by LPN C, dated 9/6/22 at 11:58 a.m. revealed resident is alert and oriented watching tablet and took meds as ordered meds, blood sugar was 112, scheduled insulin was given, no SSC. Further review of the Progress Notes, dated 9/6/22, revealed an addendum to the 11:58 a.m. note written by LPN C that stated the blood sugar was 155 not 112. This addendum was time stamped for 2:17 p.m. on 9/6/22. Review of R#41's Progress Note dated 9/6/22 at 12:31 p.m. revealed resident was found lethargic and had vomited x 1, emesis basin given. Resident alert but lethargic. VS [vitals] BP [blood pressure] 120/78, pulse 80, O2 [oxygen] SAT [saturation] 94% 2L [liter], TEMP [temperature] 97.5. Notified MD [physician] and was given order to send out to ER [emergency room ] for further evaluation. Left via stretcher per EMS [emergency medical services]. Review of hospital records, dated 9/6/22, revealed R#41 patient was drowsy. The patient was given 0.4 mg of [MEDICATION(S)] [opioid overdose treatment] and after approximately 10 minutes she was more arousable, blood pressure did improve into the 130's when patient became more alert and oriented. Suspect oversedation in addition to [CONDITION(S)] (low sodium) and [CONDITION(S)] (urinary tract infection). Medication administration - [MEDICATION(S)] 0.4 mg/ml vial: 0.4 mg IV push three times for increased drowsiness/unresponsiveness. Interview on 9/6/22 at 1:16 p.m. with LPN C with the Assistant Director of Nursing (ADON) present. LPN C confirmed she administered R#41 a dose of insulin at 11:00 a.m., not knowing if the resident ate breakfast or not. She stated she checked residents blood sugar when the resident vomited earlier. LPN C stated she did not document the blood sugar on the electronic medical record (EMR). She walked to medication cart and pulled out a glucometer and showed the surveyor a blood sugar reading of 112. She stated she was unsure of the exact time the blood sugar was checked, because the glucometer had the incorrect time on it. She stated after finding resident difficult to arouse, she asked the two CNA's working on the hall (CNA A and CNA B) if R#41 had eaten her breakfast meal and they both confirmed the resident did not eat breakfast or lunch. She stated R#41 was sent to the emergency room (ER) for unresponsiveness. Interview on 9/8/22 at 4:10 p.m., the ADON stated the hospital nurse told her they administered [MEDICATION(S)] to R#41 because they felt she was over sedated. The ADON stated LPN C should not have administered R#41's anxiety med, [MEDICATION(S)], and [MEDICATION(S)] medications the morning of 9/6/22 due to her unresponsive status. During further interview, the ADON stated she was aware LPN C administered insulin to R#41 at lunch time on 9/6/22 even though she hadn't eaten breakfast or lunch meal. The ADON confirmed the physicians order instructed the nurse not to give insulin if resident had not eaten. She stated her expectation is for staff not to have administered these medications due to R#41 being difficult to arouse. Phone interview on 9/9/22 at 12:37 p.m. with the Medical Director (MD) stated he was aware of R#41's condition and being sent to the ER. He stated he did not remember discussing with the facility about R#41 not eating her breakfast and lunch meals that day, or that she had received medications with sedative effects, when she was difficult to arouse. He stated her insulin was administered because her blood sugar was within parameters. During further interview, he stated his expectation is for the nurses to follow the orders, and to use good nursing judgement. Cross Refer F658, F580

Based on observations, record review, interviews, review of job descriptions, policy review, and Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, the facility failed to maintain professional nursing standards of quality regarding medication administration. Specifically, Licensed Practical Nurse (LPN) C administered insulin and medications with sedative effects for one resident (R) (R#41) when resident didn't eat breakfast or lunch and was difficult to arouse. In addition, the facility failed to notify the physician for change in condition for R#41. Harm was identified on 9/6/22 when R#41 required treatment with [MEDICATION(S)] for unresponsiveness and opioid overdose in the emergency room . Findings include: Review of the Charge Nurse- LPN (Licensed Practical Nurse]) job description for drug administration and documentation, undated, revealed prepare and administer medications under the direction of an RN (Registered Nurse) and as ordered by the physician in accordance with nursing standards and facility policies. Sign, dates and performs all charting and recordkeeping in accordance with established policies and procedures. Review of the undated policy titled Medication Administration, revealed medications are administered in accordance with orders of the attending physician. If a dose seems excessive considering the patient's age and condition, or a medication order seems to be unrelated to the patient's current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This interaction with the physician is documented in the nursing notes and elsewhere in the medical record as appropriate. Review of the Georgia Rule 410-10-.02 - Standards of Practice for Licensed Practical Nurses revealed that: The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician practicing medicine, a dentist practicing dentistry, a podiatrist practicing podiatry, or a registered nurse practicing nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations. (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [CONDITION(S)], specialty labs, home health care, or other such areas of practice. (c) Performing comfort and safety measures. (d) Administering treatments and medications by various routes. Review of the clinical record revealed R#41 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 12, indicating moderate cognitive impairment. Section N revealed R#41 received insulin injections, antianxiety and opioid medications, seven of seven days. Review of R#41's September 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] [insulin] 100 unit/ml (Milliliter) vial give 15 units subcutaneously (subq) before meals. Hold if NPO [nothing by mouth] or not eating, order date 4/28/22. -[MEDICATION(S)] [insulin] 100 unit/ml give 30 units subq twice daily, order date 4/28/22. -[MEDICATION(S)] [muscle relaxant] 20 mg [milligram] tablet, one tablet by mouth every six hours, order date 2/6/18. -[MEDICATION(S)] [nerve pain medication] 150 mg capsule take one capsule by mouth every six hours scheduled, order date 4/25/22. -[MEDICATION(S)] [narcotic] HCL [[MEDICATION(S)]] 20 mg tablet, one tablet by mouth every 6 hours, order date 4/5/2020. -[MEDICATION(S)] [sedative] 0.5 mg tablet give one tablet by mouth twice a day, order date 3/8/22. Review of the September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 9/6/22 at 10:56 a.m., revealed R#41 was asleep in bed. Observation on 9/6/22 at 12:19 p.m., Certified Nursing Assistant (CNA) A brought R#41's lunch tray into her room and then came right back out with the resident's tray, returning it to the hall cart. CNA A was asked about bringing R#41's tray out of the room, and she stated she couldn't arouse R#41 to eat. She revealed she would tell the nurse, stating the resident's blood sugar is low and continued to pass trays. At this time, CNA B stated R#41 has been that way [difficult to arouse] all morning. Observation on 9/6/22 at 12:20 p.m., R#41 was observed in bed with her eyes closed and with a yellow liquid substance on the sheets and a plastic basin next to her left side of the head of the bed. Review of Progress Note, written by Licensed Practical Nurse (LPN) C, dated 9/6/22 at 8:29 a.m. revealed resident was unable to arouse enough to wake and eat breakfast, tried several times, VSS [vital sign stable]. Further review of the Progress Notes revealed no evidence that the physician was notified that R#41 had a change in condition and that staff was unable to arouse her. Review of Meal Percentage Roster dated 9/4/22 through 9/7/22, revealed on 9/6/22 documented intake for breakfast was 0% and lunch was 0%. Review of the September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Progress Notes, written by LPN C, dated 9/6/22 at 11:58 a.m. revealed resident is alert and oriented watching tablet and took meds as ordered meds, blood sugar was 112, scheduled insulin was given, no SSC. Further review of the Progress Notes, dated 9/6/22, revealed an addendum to the 11:58 a.m. note written by LPN C that stated the blood sugar was 155 not 112. This addendum was time stamped for 2:17 p.m. on 9/6/22. Observation on 9/6/22 at 12:30 p.m., LPN C was observed to enter R#41's room and completed vitals that included blood pressure, pulse, oxygen saturations, and temporal artery temperature. LPN C was noted to have difficulty arousing R#41, using sternal rubs, and calling the resident's name and still, no response. LPN C then stated she was going to have to send R#41 out to the hospital. Review of R#41's Progress Note dated 9/6/22 at 12:31 p.m. revealed resident was found lethargic and had vomited x 1, emesis basin given. Resident alert but lethargic. VS [vitals] BP [blood pressure] 120/78, pulse 80, O2 [oxygen] SAT [saturation] 94% 2L [liter], TEMP [temperature] 97.5. Notified MD [physician] and was given order to send out to ER [emergency room ] for further evaluation. Left via stretcher per EMS [emergency medical services]. Review of Telephone Order, dated 9/6/22 at 12:31 p.m., located on the hard chart, revealed an order to send resident to ER for evaluation. Review of the Emergency Medical System (EMS) documentation provided by the facility revealed R#41 was transported on 9/6/22 at 1:05 p.m. Review of hospital records, dated 9/6/22, revealed R#41 patient drowsy. the patient was given 0.4 mg of [MEDICATION(S)] [opioid overdose treatment] and after approximately 10 minutes she was more arousable, blood pressure did improve into the 130's when patient became more alert and oriented. Suspect oversedation in addition to [CONDITION(S)] (low sodium) and [CONDITION(S)] (urinary tract infection) . Medication administration- [MEDICATION(S)] 0.4 mg/ml vial: 0.4 mg IV push. Further review of the hospital documentation revealed R#41 had received [MEDICATION(S)] HCL [[MEDICATION(S)]] 0.4mg/ml vial: 0.4 mg IV push three times for increased drowsiness/unresponsiveness. [MEDICATION(S)] is a medication used to reverse the effect of decreased breathing due to opioid overdose. Interview on 9/6/22 at 1:16 p.m. with LPN C with the Assistant Director of Nursing (ADON) present, LPN C confirmed she administered R#41 a dose of insulin at 11:00 a.m., not knowing if the resident ate breakfast or not. LPN C stated she checked residents blood sugar when the resident vomited earlier. LPN C stated she did not document the blood sugar on the electronic medical record (EMR). She walked to medication cart and pulled out a glucometer and showed the surveyor a blood sugar reading of 112. She stated she was unsure of the exact time the blood sugar was checked, because the glucometer had the incorrect time on it. She stated after finding resident difficult to arouse, she asked the two CNA's working on the hall (CNA A and CNA B) if R#41 had eaten her breakfast meal and they both confirmed the resident did not eat breakfast or lunch. She stated R#41 was sent to the emergency room (ER) for unresponsiveness. Interview on 9/7/22 at 1:44 p.m. with CNA B stated that she had informed LPN C that R#41 did not eat her breakfast meal. During further interview, CNA B went on to say she documented in residents medical record that she had not eaten breakfast or lunch meal on 9/6/22. On 9/8/22 at 2:54 p.m. and again at 4:28 p.m. attempts to call LPN C to obtain additional information were unsuccessful. Interview on 9/8/22 at 4:10 p.m., the ADON stated the hospital nurse told her they administered [MEDICATION(S)] to R#41 because they felt she was over sedated. The ADON stated LPN C should not have administered R#41's anxiety med, [MEDICATION(S)], and [MEDICATION(S)] medications the morning of 9/6/22 due to her unresponsive status. During further interview, the ADON stated she was aware LPN C administered insulin to R#41 at lunch time on 9/6/22 even though she hadn't eaten breakfast or lunch meal. The ADON confirmed the physicians order instructed the nurse not to give insulin if resident had not eaten. She stated her expectation is for staff not to have administered these medications due to R#41 being difficult to arouse. Phone interview on 9/9/22 at 12:37 p.m. with the Medical Director (MD) stated he was aware of R#41's condition and being sent to the ER. He stated he did not remember discussing with the facility about R#41 not eating her breakfast and lunch meals that day, or that she had received medications with sedative effects, when she was difficult to arouse. He stated her insulin was administered because her blood sugar was within parameters. During further interview, he stated his expectation is for the nurses to follow the orders, and to use good nursing judgement. Cross Refer: F760

Based on observations, record review, interviews, and policy review, the facility failed to notify the physician for a change in condition for one of two residents (R) (R#41) reviewed for change in conditions. Specifically, R#41 suffered harm as result of staff administering insulin and medications with a sedative effect when resident was difficult to arouse, requiring treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the Change in a Resident's Condition or Status policy, revised May 2017, revealed number 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): c. adverse reaction to medication; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly. Review of the clinical record revealed R#41 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 12, indicating moderate cognitive impairment. Section N revealed R#41 received insulin injections, antianxiety and opioid medications, seven of seven days. Review of R#41's September 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if NPO (nothing by mouth) or not eating (ordered 4/28/22); [MEDICATION(S)] insulin 100 unit/ml give 30 units subcutaneously twice daily (ordered 4/28/22); [MEDICATION(S)] (muscle relaxant) 20 mg (milligram) one tablet by mouth every six hours (ordered 2/6/18); [MEDICATION(S)] (nerve pain medication) 150 mg capsule by mouth every six hours (ordered 4/25/22); [MEDICATION(S)] (narcotic pain medication) 20 mg by mouth every six hours (ordered 4/5/2020); [MEDICATION(S)] (anti-anxiety) 0.5 mg one tablet by mouth twice a day (ordered 3/8/22). Review of the September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 9/6/22 at 10:56 a.m. revealed R#41 was asleep in her bed. Observation on 9/6/22 at 12:19 p.m., Certified Nursing Assistant (CNA) A brought R#41's lunch tray into her room and then came right back out with the resident's tray, returning it to the hall cart. CNA A was asked about bringing R#41's tray out of the room, and she stated she couldn't arouse R#41. She revealed she would tell the nurse, stating the resident's blood sugar is low and continued to pass trays. At this time, CNA B stated R#41 has been that way [difficult to arouse] all morning. Observation on 9/6/22 at 12:20 p.m., R#41 was observed in bed with her eyes closed and with a yellow liquid substance on the sheets and a plastic basin next to R#41's left side of the head of the bed. Review of R#41's Progress Note, written by Licensed Practical Nurse (LPN) C, dated 9/6/22 at 8:29 a.m. revealed resident was unable to arouse enough to wake and eat breakfast, tried several times, VSS [vital sign stable]. Further review of the Progress Notes revealed no evidence that the physician was notified that R#41 had a change in condition and that staff was unable to arouse her. Review of the Progress Notes, written by LPN C, dated 9/6/22 at 11:58 a.m. revealed resident is alert and oriented watching table [sic] took meds as ordered, blood sugar was 112, scheduled insulin was given, no SSC (sliding scale coverage). Further review of the Progress Notes, dated 9/6/22, revealed an addendum to the 11:58 a.m. note written by LPN C that stated the blood sugar was 155 not 112. This addendum was time stamped for 2:17 p.m. on 9/6/22. Observation on 9/6/22 at 12:30 p.m., LPN C was observed to enter R#41's room and completed vitals that included blood pressure, pulse, oxygen saturations, and temporal artery temperature. LPN C was noted to have difficulty arousing R#41, using sternal rubs, and calling the resident's name and still, no response. LPN C then stated she was going to have to send R#41 out to the hospital. Review of R#41's Progress Note dated 9/6/22 at 12:31 p.m. revealed resident was found lethargic and had vomited x 1, emesis basin given. Resident alert but lethargic. VS [vitals] BP [blood pressure] 120/78, pulse 80, O2 [oxygen] SAT [saturation] 94% 2L [liter], TEMP [temperature] 97.5. Notified MD [physician] and was given ordered to send out to ER [emergency room ] for further evaluation. Left via stretcher per EMS [emergency medical services]. Review of R#41's Telephone Order, dated 9/6/22 at 12:31 p.m., located on the hard chart, revealed an order to send resident to ER for evaluation. Review of the Emergency Medical System (EMS) documentation provided by the facility revealed R#41 was transported on 9/6/22 at 1:05 p.m. Review of R#41's hospital records, dated 9/6/22, provided by the Assistant Director of Nursing (ADON), revealed R#41 patient drowsy. the patient was given 0.4 mg of [MEDICATION(S)] [opioid overdose treatment] and after approximately 10 minutes she was more arousable, blood pressure did improve into the 130's when patient became more alert and oriented. Suspect oversedation in addition to [CONDITION(S)] (low sodium) and [CONDITION(S)] (urinary tract infection) . Medication administration- [MEDICATION(S)] 0.4 mg/ml vial: 0.4 mg IV push. Further review of the hospital documentation, provided by the facility, revealed R#41 received [MEDICATION(S)] HCL [[MEDICATION(S)]] 0.4mg/ml vial: 0.4 mg IV push three times for increased drowsiness/unresponsiveness. [MEDICATION(S)] is a medication used to reverse the effect of decreased breathing due to opioid overdose. Phone interview on 9/9/22 at 12:37 p.m. with the Medical Director (MD) stated he was aware of R#41's condition and being sent to the ER. He stated he did not remember discussing with the facility about R#41 not eating her breakfast and lunch meals that day. He stated her insulin was administered because her blood sugars were within parameters. The MD continued to say he didn't remember discussing R#41 receiving medications with sedative effects such as [MEDICATION(S)] when R#41 had been difficult to arouse earlier, as these medications would make her condition worse. During further interview, he stated his expectation is for the nurses to follow the orders. Cross Refer: F760, F658