Every finding on record at St. Joseph's Care Center

Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for dietary services. The facility failed to ensure food was safely stored, labeled, and dated in the upright refrigerator on 08/11/26.The facility failed to ensure food was safely stored, labeled, and dated in the upright freezer on 08/11/2026. These failures have the potential to affect the residents who ate food from the facility's kitchen, placing them at risk of foodborne illnesses.Findings include: Observation of the facility's kitchen on 08/11/26 at 9:22 AM revealed the following:There were 2 unopened cartons of sour cream in the refrigerator that did not have a received date on them.There was one bag in the freezer that had cooked barbeque pork written on it and a date of 06/04/26 on it but did not have a used by date written on it.There was a rigid plastic bin with small packages of sugar in it on the counter top by the front door in the kitchen that did not have a received date or a used by date on it.There was one loaf of raisin bread in the refrigerator with a preparation date of 06/16 and a use by date 06/23/26 written on it.There was a case of 20 eggs in the refrigerator that did not have a received date or a use by date on the carton.There was a bag of unidentified meat in the freezer that did not have a received date, open date, or a used by date on it.There was one bag with barbeque pork written on it in the freezer and it had an opened date of 05/10/26 and a used date of 08/10/26 on the bag.There was one bag with steak written on it in the freezer with a prep date of 05/20 and a used by date of 05/30 written on it. There was not a year listed on the label.There was one bag of link sausages in the freezer with an unidentified date of 07/30 /26 on the bag.There was one bag of thawed ground beef with a prep date listed as 'thawed on 06/22/26 and a used by date of 06/27/26 in the freezer.There was one bag of 41/50 count bag of raw peeled deveined white shrimp (2.5 pounds) that did not have any dates on it in the freezer.There was one bag with cooked pulled pork written on it in the freezer and had a date 06/14/26 listed on it. There were no other dates listed.There was one bag labeled Meat sauce and meatballs in the freezer with a date of 08/06/26 listed on it. There were no other dates listed.There was one bag of yellow pasteurized process cheese spread in the freezer with a preparation date of 03/24/26 and a used by date of 07/01/26 written on it.There was one bag of yellow pasteurized process cheese spread in the freezer with a preparation date of 06/16/26 and a use by date of 07/01/26 written on it.There was an open bag of bread sticks in the freezer with a preparation date of 08/10/26 written on it. There were no other dates listed.There was an open bag of white shredded cheese in the refrigerator with an open date of '07/11/24' and a use by date of 07/26/26. During an interview on 08/13/26 at 9:08 AM, the DA said the facility had a policy on labeling, dating, and food storage and she was trained on the policy. She said the last training was about a month ago and they were trained on the policy often. She said once a food package was opened or prepared, she would put that day's date and the use-by date on the items. DA stated she was responsible for Juice and milk only and there was a separate refrigerator for those items. DA said DM was responsible for ensuring refrigerators, freezers, and dry storages items were stored and dated correctly. However, she said she was responsible for ensuring that all items in the front refrigerator, which had only liquids in it, were dated correctly. She said that she was also responsible for ensuring the ice cream cups located in the front of the kitchen were dated correctly. DA said if she found food in the refrigerator or freezer that did not have a date on it, she would ask if anyone put it in there. If she did not get a response, then she would throw it away. If someone told her they put it in the refrigerator, she would ask them for the date, which would determine whether to keep it or throw it away, depending on if it was more than 3 days. DA stated she discarded items out of the refrigerator 3 days after the date they were put in the refrigerator / freezer. DA said it was important to ensure the dates were correct on food so residents would not get old and stale food, which could make them sick. During an interview with the DM on 8/13/26 at 9:17 AM, she said that the facility had a policy on labeling, dating, and food storage and she was trained on the policy. She said the last training was about a month ago and they were trained on the policy often. DM said the receive date was the date the food was delivered to the facility. She said there was an open date, prepared date, and a discard date on the package as well. She said she was responsible for ensuring all food items were dated correctly. DM also said the cooks and other dietary aids had separate refrigerators and freezers to check daily. DM said the last inspection was the day before, which was 08/12/26. She said an inspection of the refrigerators, freezers, and all other food storage areas should be completed daily by all shifts. DM said she was not aware that the food was not dated correctly and there was expired food in the freezer. She said the reason she was not aware of this was because she was on vacation for a week recently and she had a staff member quit. She said all staff received in-service training on dates, storage, and labeling all the time. She said once the problems were identified, she went through the refrigerators and freezers and checked all the food for dates and discarded expired items. She said she also spoke with her staff and educated them on the food labeling and dating policy. DM said the importance of ensuring dates and labels were correct and expired food was thrown out of the kitchen was to ensure residents did not eat old food, which could make them sick from food-borne illnesses. During an interview on 08/13/26 at 9:42 AM with the ADM, she said the facility had a policy on food labeling, dating, and food storage. ADM said the last training was about a month ago and all kitchen staff were trained on the policy often. She stated she depended on the DM to ensure the policy was followed. She said she went into the kitchen once a week to make sure DM was doing what she was supposed to be doing and DM told her yes. She said DM has the ultimate responsibility for monitoring dietary food labeling and storage. ADM said that the dietician came once a month and completed a walk through to ensure that everything was correct in the kitchen. ADM said she was not aware that food was not dated correctly and there was also expired food in the kitchen. She said this had not happened while she was here and did not know why it happened. She said she did not know of any residents exposed to expired food at the facility. DM said the importance of ensuring food was dated, labeled, and stored correctly was to ensure that food was not contaminated or old and all expired food was thrown away. She said this could prevent residents from getting sick from food borne illnesses. ADM said she would make more rounds in the kitchen and request more visits from the dietician. She said it would hold DM accountable. Record review of the food dating, labeling and storage policy (undated) revealed the following: Purpose: to establish a consistent process for identifying, dating, labeling, storing, rotating, and discarding food to promote food safety and prevent the use of service of expired, improperly identified, or improperly dated food. Policy:The facility will ensure that food requiring identification and/or date marking is properly labeled, stored, and discarded in accordance with applicable food-safety requirements, manufacturer instructions, and facility policy. Food labels must be complete, legible, accurate, and readily visible. When more than one use-by or discard date applies, the earliest applicable date will be used. IF the manufacturer's use-by or expiration date occurs sooner than the facility-calculated used-by / discard date, the manufacturer's earlier date MUST be followed. Manufacturer use-by or expiration dates will not be extended. Procedure: Dietary staff will complete the food rotation label as applicable:Dietary staff will complete the food rotation as applicable: Item: clearly identify the food or product Prep date: Document the date the food was prepared, opened, orrepackaged, as applicable. Use by: document the appropriate use-by / discard date: Employee: the employee preparing, opening, repackaging, or labeling thefood will initial the label as applicable. Date Marking Requirements Food requiring identification or date marking must be labeled promptly after preparation, opening, or repackaging. Refrigerators, freezers, dry storage areas, and other food-storage locations will be routinely checked for:Proper identificationComplete and legible labelsAppropriate preparation/open datesAppropriate use-by/discard datesManufacturer expiration or use-by datesProper storage and rotationExpired or questionable products Expired, unlabeled, and or questionable food:Food will not be served when it is expired, improperly labeled, cannot be positively identified, or when the appropriate preparations/opening or use-by/discard date cannot be verified as required.Such food will be removed from service and handled according to the facility food safety procedures.When in doubt, staff must STOP and consult the DM before the food is used or served. Staff education:Dietary staff will receive education regarding proper food identification, dating, labeling, storage, rotation, manufacturer dates, and the facility's food-safety procedures.

Based on observations, interviews, and record review, the facility failed to ensure the resident had a right to confidentiality of his or her personal and medical records for 11 of 20 residents (Residents #46, #16, #40, #35, #11, #42, #44, #29, #24, #57 and #45) reviewed for privacy and confidentiality. The facility failed to ensure Residents #46, #16, #40, #35, #11, #42, #44, #29, #24, #57 and #45vital sign information was not left exposed on top of MA A's medication cart unattended on 08/11/26. These failures could place the residents at risk of not having their personal privacy maintained during medication administration and their medical information exposed to unauthorized individuals. Findings included: Record review of Resident #46's admission Record, dated 08/12/26, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), diabetes (a group of diseases that result in too much sugar in the blood), chronic kidney disease (long standing disease of the kidneys leading to renal failure), and anxiety (intense, excessive, and persistent worry and fear about everyday situations).Record review of Resident #46's Quarterly MDS Assessment, dated 05/11/26, reflected the resident had a BIMS score of 15 which indicated resident was cognitively intact.Record review of Resident #16's admission Record, dated 08/12/26, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens), atrial fibrillation (a common heart arrhythmia that causes the upper chambers of the heart to beat irregularly and often rapidly), osteoarthritis (a degenerative joint disease that causes the cartilage and bone in a joint to break down over time), and venous insufficiency (a long-term condition where leg veins fail to send blood back up to the heart efficiently).Record review of Resident #16's admission MDS Assessment, dated 06/29/26, reflected the resident had a BIMS score of 06 which indicated resident was severely cognitively impaired.Record review of Resident #40's admission Record, dated 08/12/26, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), hypercholesterolemia (a condition with too much low-density lipoprotein, or bad cholesterol, in the blood), and hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated).Record review of Resident #40's admission MDS Assessment, dated 06/08/26, reflected the resident had a BIMS score of 08 which indicated resident was moderately cognitively impaired.Record review of Resident #35's admission Record, dated 08/12/26, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included benign prostatic hyperplasia (BPH) (a common noncancerous enlargement of the prostate gland in men, typically occurring with aging, which causes lower urinary tract symptoms like weak stream, frequency, and nocturia), dysphagia (difficulty in swallowing), atrial fibrillation (a common heart arrhythmia that causes the upper chambers of the heart to beat irregularly and often rapidly), and anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood).Record review of Resident #35's admission MDS Assessment, dated 08/06/26, reflected the resident had a BIMS score of 13 which indicated resident was cognitively intact.Record review of Resident #11's admission Record, dated 08/12/26, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included diabetes (a group of diseases that result in too much sugar in the blood), chronic obstructive pulmonary disease (a lung disease characterized by chronic respiratory symptoms and airflow limitation), atherosclerotic heart disease of native coronary artery (coronary artery disease) (heart disease involving the reduction of blood flow to the cardiac muscle due to a buildup of atheromatous plaque in the arteries of the heart), and hyperlipidemia (abnormally high levels of any or all lipids or lipoproteins in the blood).Record review of Resident #11's Quarterly MDS Assessment, dated 07/04/26, reflected the resident had a BIMS score of 12 which indicated resident was moderately cognitively impaired.Record review of Resident #42's admission Record, dated 08/12/26, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included idiopathic generalized epilepsies (now often termed genetic generalized epilepsies) (a group of epilepsy syndromes linked to genetic factors. Features include frequent brief staring spells, absence seizures, tonic-clonic convulsions, quick shock-like muscle jerks), bipolar disorder (a chronic mental health condition characterized by extreme mood swings, alternating between intense highs [mania or hypomania] and severe lows [depression], depression [feelings of severe despondency and dejection]), and hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated).Record review of Resident #42's Quarterly MDS Assessment, dated 05/31/26, reflected the resident had a BIMS score of 03 which indicated resident was severely cognitively impaired.Record review of Resident #44's admission Record, dated 08/12/26, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included cerebral infarction (a pathologic process that results in an area of necrotic tissue in the brain), diabetes (a group of diseases that result in too much sugar in the blood), hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), and benign prostatic hyperplasia (BPH) (a common noncancerous enlargement of the prostate gland in men, typically occurring with aging, which causes lower urinary tract symptoms like weak stream, frequency, and nocturia).Record review of Resident #44's Annual MDS Assessment, dated 07/28/26, reflected the resident had a BIMS score of 07 which indicated resident was severely cognitively impaired.Record review of Resident #29's admission Record, dated 08/12/26, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included hypothyroidism (a disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormones), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety (intense, excessive, and persistent worry and fear about everyday situations).Record review of Resident #29's Quarterly MDS Assessment, dated 07/29/26, reflected the resident had a BIMS score of 03 which indicated resident was severely cognitively impaired.Record review of Resident #24's admission Record, dated 08/12/26, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), chronic obstructive pulmonary disease (a lung disease characterized by chronic respiratory symptoms and airflow limitation), peripheral vascular disease, also known as peripheral artery disease, (a condition that occurs when blood vessels narrow or become blocked, reducing blood flow to the body. Peripheral vascular disease can affect any blood vessel outside of the heart, but it most commonly affects the legs and feet), and hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated).Record review of Resident #24's admission MDS Assessment, dated 06/02/26, reflected the resident had a BIMS score of 15 which indicated resident was cognitively intact.Record review of Resident #57's admission Record, dated 08/12/26, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included atherosclerotic heart disease of native coronary artery (coronary artery disease) (heart disease involving the reduction of blood flow to the cardiac muscle due to a buildup of atheromatous plaque in the arteries of the heart), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood), hyperlipidemia (abnormally high levels of any or all lipids or lipoproteins in the blood), and scoliosis (a medical condition that causes the spine to curve sideways, often forming an S- or C-shape).Record review of Resident #57's admission MDS Assessment, dated 08/07/26, reflected the resident had a BIMS score of 04 which indicated resident was severely cognitively impaired.Record review of Resident #45's admission Record, dated 08/12/26, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), diabetes (a group of diseases that result in too much sugar in the blood), chronic obstructive pulmonary disease (a lung disease characterized by chronic respiratory symptoms and airflow limitation), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).Record review of Resident #45's admission MDS Assessment, dated 08/03/26, reflected the resident had a BIMS score of 02 which indicated resident was severely cognitively impaired.During an observation on 08/11/26 at 10:02 AM, an opened notepad which exposed residents names, blood pressures, and pulses was sitting on top of the medication cart that had been used by MA A during medication administration outside of the therapy gym door in view of other residents.During an interview on 08/11/26 at 10:23 AM, MA A stated she worked with a staffing agency and she was called in to help the facility out with administering medications to residents. She stated there were residents' names and vital signs that included their blood pressures and pulses on the note pad that was left exposed on top of the medication cart outside of the therapy gym in the facility. She stated she had been trained on resident privacy and resident rights. She stated if resident information was left exposed for others to see it could have been a violation of residents' privacy and rights.During an interview on 08/13/26 at 10:45 AM, the DON stated staff had been trained on privacy and resident rights. She stated anything containing resident information should be put away and not left out for anyone to see. She stated it would have been a violation of HIPAA if resident information was left out for others to see and it would have been a violation of resident rights and privacy.During an interview on 08/13/26 at 11:00 AM, the ADM stated staff had been trained on privacy and resident rights. She stated anything containing resident information should be put away and not left out for anyone to see. She stated it would have been a violation of HIPAA if resident information was left out for others to see and it would have been a violation of resident rights and privacy.Record review of the facility's undated policy titled Resident Rights reflected Policy: Resident Rights. Purpose: To ensure that resident rights are respected and protected. To inform residents of their rights and provide an environment in which they can be exercised. Procedure: Residents do not leave their individual personalities or basic human rights behind when they move to a long term care facility. Following is a list of resident rights recognized by management and employees as well as local, state and federal laws and regulations. The resident has the right: To personal privacy and confidentiality of their person and medical records.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents reviewed for medication administration (Resident #45) and for 1 of 1 clean linen area of facility.MA A failed to sanitize the blood pressure cuff when going from one resident to another resident when obtaining blood pressure during medication administration for Resident #45 on 08/11/26.Facility failed to prevent clean linens from being exposed to contaminants when LA B left open food and a drink out in close proximity to clean linens on 08/12/26.This deficient practice placed residents at risk for cross contamination and the spread of infection.Findings included:Record review of Resident #45's admission Record, dated 08/12/26, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), diabetes (a group of diseases that result in too much sugar in the blood), chronic obstructive pulmonary disease (a lung disease characterized by chronic respiratory symptoms and airflow limitation), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).Record review of Resident #45's admission MDS Assessment, dated 08/03/26, reflected the resident had a BIMS score of 02 which indicated resident was severely cognitively impaired.During an observation on 08/11/26 at 9:58 AM, MA A obtained Resident #45's blood pressure reading without sanitizing the blood pressure cuff after she obtained another resident's blood pressure reading.During an interview on 08/11/26 at 10:23 AM, MA A stated she worked with a staffing agency and she was called in to help the facility out with administering medications to residents. She stated she had not sanitized the blood pressure cuff when she went from obtaining a blood pressure on one resident to obtaining a blood pressure on Resident #45. She stated she would have normally sanitized the blood pressure cuff in between residents. She stated she has been trained on sanitizing the blood pressure cuff when she went from one resident to the next resident and also on infection control. She stated if she had not sanitized the blood pressure cuff when going from one resident to the next resident, it could have spread germs, body fluids, or infectionDuring an observation on 08/12/26 at 9:46 AM, an open food wrapper with a partially eaten biscuit and sausage and a drinking cup with a lid that had a small opening for drinking were present on top of the counter approximately 4 inches from clean linen sitting on the counter of the clean linen folding counter in the clean linen area of the facility.During an interview on 08/12/26 at 10:10 AM, LA B stated her title was laundry aide and she had worked at the facility for about a year. She stated she had not received training on infection control and was not familiar with the concept of clean versus dirty. She stated the infection control training may have been reviewed in her orientation when she began working at the facility. She stated the food and drink that was in the clean laundry room sitting on the folding table belonged to her and she was aware food and drink should not have been in the clean linen room, or close to the clean linens. She stated she did not know how far food should be kept from clean linen. She stated if food was close to the linen, it could have caused contamination, like bacteria. She stated that she should have probably kept her food in the break room.During an interview on 08/13/26 at 10:45 AM, the DON stated staff had been trained on infection control and prevention. She stated multi-use resident equipment, such as a blood pressure cuff, should have always been sanitized when used between each resident. She stated if multi-use resident equipment had not been sanitized in between residents, it could have led to infection or the spread of bacteria for residents. She stated no opened food or drink should have been left out in close proximity to clean linen. She stated if opened food or drink was left out in close proximity to clean linen it could have caused bacteria to spread onto the linen and it could have led to infection for the resident.During an interview on 08/13/26 at 11:00 AM, the ADM stated staff had been trained on infection control and prevention. She stated multi-use resident equipment, such as a blood pressure cuff, should have always been sanitized when used between each resident. She stated if multi-use resident equipment had not been sanitized in between residents, it could have led to cross contamination or the spread of infection. She stated no opened food or drink should have been left out in close proximity to clean linen. She stated if opened food or drink was left out in close proximity to clean linen it could have spilled and possibly caused the spread of infection.Record review of the undated facility policy titled Shared Resident Equipment Cleaning/Disinfecting reflected the following: Purpose: To promote a safe environment by ensuring shared resident equipment is cleaned and disinfected routinely and between uses. Policy: Shared resident care equipment will be cleaned and disinfected as needed to reduce the risk of spreading infection. Staff are responsible for maintaining equipment in a clean condition and following facility infection prevention practices. Definitions: Shared Resident Equipment: Any equipment used by more than one resident. Procedure: Clean and disinfect shared equipment between resident uses and when visibly soiled. Follow facility-approved cleaning and disinfection practices. Responsibilities: Staff using equipment are responsible for ensuring it is cleaned and disinfected appropriately.Record review of the undated facility policy titled Infection Prevention and Control Program Standards, Policies and Procedures reflected Infection Control Expectations: All staff are expected to: Prevent cross contamination, Clean shared equipment. Proper infection control practices protect residents, staff, and the entire facility community. Infection Prevention and Control Guidelines: May include but are not limited to: Always observe standard precautions or other infection control standards as approved by the appropriate facility committee, Medical Director or procedure. Maintain sterility or cleanliness of the equipment and working field as necessary.Record review of the undated facility policy titled Laundry Policy reflected To reduce the risk to all laundry staff associated with handling of laundry that is potentially or contaminated with an infectious agent. Ensure that standards are in place for infection control to enable patient well-being. Help minimize risk of infection control issues. In accordance with the Health and Safety Act 1974, all staff are to ensure that correct procedures are adopted to ensure that staff and patients are not at risk from used or infected linen. Accountability and Responsibility: Laundry Supervisor and Administrator are responsible for ensuring that all staff are familiar with the policy and that safe management of linen and laundry is carried out in accordance with legislation, policies and best practice. All staff that has anything to do with handling linen and laundry must ensure that they are aware of their role in the prevention of healthcare associated infection. Linen Storage: Clean Laundry Linen should be stored in a designated storage area clean linen must not be stored in linen closet, bathroom, or laundry room. The designated storage area should be kept clean and free from infestation by insects and the residents' clean laundry should be stored above oor level. Clean laundry should be kept tidy to avoid recontamination.

Based on observations, interviews, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 4 residents (Resident #24) who were reviewed for accuracy of assessments.Resident #24's comprehensive MDS was not coded with the hospice benefit, when the resident was receiving hospice services.This failure placed residents at risk of a lack of coordination of care and services necessary for their physical, mental, and psychosocial well-being.Findings included:Review of Resident #24's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnosis: high blood pressure, heart failure, high cholesterol, depression, drug induced subacute dyskinesia (medication related movement disorder characterized by involuntary, repetitive movements that develop over days to weeks after exposure to certain drugs), polyneuropathy (the breakdown of peripheral nerves that typically affect multiple nerves), acquired absence of right leg below knee. In Section O - Special Treatments, Procedures, and Programs, there was no 'x' in the Hospice Care line indicating Resident #24 was on hospice. In Section J - Health Conditions, question 'J1400 Prognosis' indicated a '0' indicating the resident did not have a chronic disease or condition that may result in a life expectancy of less than 6 months. Resident #24 had a BIMS score of 15, indicating intact cognition.Review of Resident #24's comprehensive care plan dated 05/27/2026 reflected under the 'Special Instructions' Call [hospice company] hospice for any emergencies and any concerns [phone number]. There was no Focus for hospice, Goals, or Interventions care planned for Resident #24 related to the facilitation of hospice services.Review of Resident #24's face sheet undated, reflected her primary payer was Hospice Medicaid.Review of Resident #24's admission progress note dated 05/26/2026 by the facility's previous DON reflected: DNR Resident is a new admission to facility. Resident was transported to facility by private vehicle. admitted from another nursing facility [name]. Admitting diagnosis: CHF, Reason for admission: HospiceIn an observation on 08/11/2026 at 10:55 AM, Resident #24 was observed lying in bed with a hospital gown hanging off the right side of her body. An interview was attempted with Resident #24, but the resident was unable to follow verbal prompts with intelligible answers and stared blankly at the surveyor. In an interview on 08/11/2026 at 11:15 AM, with LVN C, stated that she had seen a very recent decline in Resident #24. She revealed that Resident #24 was on hospice, and recently finished a course of antiviral medication, which seemed to have negatively affected Resident #24's mental status change. LVN C stated that Resident #24 had not been wanting to get up and go places and she would just look at people blankly when they tried to talk to her, and she did not respond appropriately somedays. She stated this information had been relayed to the hospice RN recently, and the hospice RN would be visiting Resident #24 tomorrow.In an interview on 08/13/2026 at 11:35 AM with the MDSC, stated that she recalled when Resident #24 was admitted to the facility. She acknowledged there were 2 sections in the MDS to indicate that a resident was receiving the hospice benefit and confirmed that Resident #24 did not have hospice indicated in either section. She stated she believed Resident #24 admitted on hospice. She stated an important reason to indicate the hospice benefit on the MDS was that it would pull over to the care plan. She stated that a negative outcome could be lack of coordination with the hospice company if these things were not documented. She stated she referred to the doctors' orders, but if the resident admitted on hospice the order would have looked a little different than what she was used to seeing admit to hospice of XX company when a new order came through.In an interview on 08/13/2026 at 12:38 PM with the QARN, stated she worked at the facility part time on the administrative side, helping update comprehensive care plans, and signing the MDS assessments indicating they were completed. She stated that she was not signing MDS assessments to validate accuracy, just signed them as being completed. She stated that there was not a process in place to ensure accuracy after the MDSC's completion of the assessment. She stated that potential negative outcomes to residents could be lack of coordination of hospice services, but there was no financial impact to the facility since hospice paid them directly.In an interview on 08/13/2026 at 12:45 PM with the ADM she stated that the MDSC was responsible for ensuring the MDS accuracy. She stated that the DON may look at the MDS but was not responsible for ensuring accuracy and that the facility's QARN signed off on the MDS assessments as completed, not accurate. She stated that negative impacts to residents could be a lack of coordination of care/services as well as financial consequences to the facility. Review of the facility's policy titled, 'Implementation of the Minimum Data Set (MDS)' revealed, It is the policy of this facility to ensure a comprehensive assessment of each resident is completed and submitted according to the RAI guidelines manual set forth by CMS.Supplies/Equipment: Current physician orders, including all orders during the observation period

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and described the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being of 1 (Resident #24) of 4 residents reviewed for care plans.The facility failed to include goals and interventions related to the hospice services Resident #24 was receiving in her care plan.This failure could place residents at risk for not receiving appropriate care and treatment. Findings included:Review of Resident #24's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnosis: high blood pressure, heart failure, high cholesterol, depression, drug induced subacute dyskinesia (medication related movement disorder characterized by involuntary, repetitive movements that develop over days to weeks after exposure to certain drugs), polyneuropathy (the breakdown of peripheral nerves that typically affect multiple nerves), acquired absence of right leg below knee. In Section O - Special Treatments, Procedures, and Programs, there was no 'x' in the Hospice Care line indicating Resident #24 was on hospice. In Section J - Health Conditions, question 'J1400 Prognosis' indicated a '0' indicating the resident did not have a chronic disease or condition that may result in a life expectancy of less than 6 months. Resident #24 had a BIMS score of 15, indicating intact cognition.Review of Resident #24's comprehensive care plan dated 05/27/2026 reflected under the 'Special Instructions' Call [hospice company] hospice for any emergencies and any concerns [phone number]. There was no Focus for hospice, Goals, or Interventions care planned for Resident #24 related to the facilitation of hospice services.Review of Resident #24's face sheet undated, reflected her primary payer was Hospice Medicaid.Review of Resident #24's admission progress note dated 05/26/2026 by the facility's previous DON reflected: DNR Resident is a new admission to facility. Resident was transported to facility by private vehicle. admitted from another nursing facility [name]. Admitting diagnosis: CHF, Reason for admission: HospiceIn an observation on 08/11/2026 at 10:55 AM, Resident #24 was observed lying in bed with a hospital gown hanging off the right side of her body. An interview was attempted with Resident #24, but the resident was unable to follow verbal prompts with intelligible answers and stared blankly at the surveyor. In an interview on 08/11/2026 at 11:15 AM, with LVN C, stated that she had seen a very recent decline in Resident #24. She revealed that Resident #24 was on hospice, and recently finished a course of antiviral medication, which seemed to have negatively affected Resident #24's mental status change. LVN C stated that Resident #24 had not been wanting to get up and go places and she would just look at people blankly when they tried to talk to her, and she did not respond appropriately somedays. She stated this information had been relayed to the hospice RN recently, and the hospice RN would be visiting Resident #24 tomorrow.In an interview on 08/13/2026 at 11:35 AM with the MDSC, stated that she recalled when Resident #24 was admitted to the facility, and she believed Resident #24 admitted on hospice. She stated if hospice was not indicated on the MDS, it would not pull over to the care plan. She stated that the purpose of having hospice on the care plan was to give the direct care staff knowledge of which hospice company to coordinate with, and to know which tasks hospice took care of. She stated that a negative outcome could be lack of coordination with the hospice company if these things were not documented. She stated she referred to the doctors' orders, but if the resident admitted on hospice the order would have looked a little different than what she was used to seeing admit to hospice of XX company when a new order came through.In an interview on 08/13/2026 at 12:38 PM with the QARN, stated she worked at the facility part time on the administrative side, helping update comprehensive care plans, and signing the MDS assessments indicating they were completed. She stated that multiple department heads have access to update the care plans but it was mostly the MDSC who used the MDS to pre-populate the care plan. She stated that potential negative outcomes to residents could be lack of coordination of hospice services, but there was no financial impact to the facility since hospice paid them directly.In an interview on 08/13/2026 at 12:45 PM with the ADM she stated that the MDSC was responsible for ensuring the MDS was accurate which would populate goals onto the care plans. She stated that negative impacts to residents could be a lack of coordination of care/services and staff not knowing which responsibilities were on them or the hospice company.Review of the facility's undated policy titled, 'Comprehensive Care Plans' revealed: 1. The facility will develop and implement a comprehensive person centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment2. The comprehensive care plan will describe the following:a. The services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being

Based on interviews and record review, the facility failed to respect the residents' right to personal privacy, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the residents, including those delivered through a means other than a postal service, for 1 resident (Res1) of 4 residents interviewed.The facility failed to respect Res1's right to privacy by opening his mail without his permission.This failure could result in Res1 losing trust in staff and feeling disrespected and violated.Findings include: Record review of Res #1's face sheet dated 09/17/2025 revealed a [AGE] year-old male was admitted on *with the following diagnoses:Quadriplegia, C1 - C4 complete (paralysis affecting all 4 limbs in the highest cervical spinal cord injury (no signals can pass though the arms, legs, trunk, or diaphragm), anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life), unspecified and depression. Record review of Res#1's MDS revealed his BIMS was 14. Record review of the grievances filed in February 2026 revealed that AADMN wrote grievance on Res #1's behalf on 02/26/2026 stating that staff opened his mail without his permission. Interview with Res #1 on 04/07/2026 at 10:29 a.m. revealed he stated that LVNA opened his mail without his permission. Res #1 said RN walked in his room to give him his mail. Res #1 said RN told him that she opened his mail because she thought there was medication in it. Res #1 said he told her that was not a reason to open his mail without asking first. He concluded that he felt LVNA disrespected him. Interview with ADMN on 04/07/2026 at 4:01 p.m. revealed the AADMN issued a verbal warning to the LVNA regarding opening Res #1's mail without his permission. ADM said this was a violation of the resident rights policy. She stated this could cause Res #1 to not trust the facility with essential information. Interview with LVNA on 04/07/2026 at 4:09 p.m. revealed she stated she opened Res #1's mail because someone told her when she was first hired to open residents' mail to ensure there was no medication in there. LVNA stated she told Res #1 she opened his mail and apologized to him. LVNA stated that AADM told her she was not supposed to open residents' mail unless she opened it in front of them with their permission. LVNA advised Res #1 did not give her permission to open his mail. LVNA concluded that she received a verbal warning from AADMN, who also reviewed the resident rights policy with her. She stated that opening residents' mail without their permission could cause the residents to not trust the staff and could also make them upset. Interview with AADMN on 04/07/2026 at 4:23 p.m. revealed she wrote a grievance on behalf of Res #1 about his mail being opened without his permission. AADMN said she issued LVNA a verbal warning and advised that staff can not open residents' mail without their permission. AADMN advised that opening a resident's mail without permission could cause them to lose trust in the facility staff.Record review of the facility's resident rights policy (undated) stated the following: Purpose:To ensure that resident rights are respected and protected.To inform residents of their rights and provide an environment in which they can be exercised.To personal privacy, including the right to privacy in oral, written, and electronic communications, including the right to send and receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than postal service

Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 1 resident (Resident #1) reviewed for safety.On 12/11/25 the facility failed to identify a hazard when Resident #1 was served her tea that was hot enough to create 1st and 2nd degree burns after it spilled on her.The facility failed to ensure staff knew the facility policy for Hot Beverage Preparation & Burn Safety and continued to serve hot liquids that were out of range from their policy limits.This failure could place cognitively impaired residents at risk for accidents, injuries, and a diminished quality of life. Findings include: Record review of Resident #1's undated face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Hypertensive Heart and Chronic Kidney disease with Heart Failure, Congestive Heart Failure, Atrial Fibrillation (poor heart rhythm) and High Blood Pressure (Hypertension). The record reflects her date of death was 12/15/25.Review of Resident #1's hospice admission form reflected the resident was on hospice as of 11/11/25 for terminal heart and kidney diseases stage 4 (last stage).Review of Resident #1's Significant change MDS assessment dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 09 indicating she is moderately cognitively impairedRecord review of Resident #1's Care Plan, reflected a Focus area was initiated for Fragile Skin on 6/10/25 with a goal to have no skin complications. Resident #1's interventions included encouraging the resident to call for assistance as needed and to observe skin for problems. Review of Resident #1's 12/11/25 Skin Occurrence report reflected on 12/11/25 at 08:00 AM the resident spilled her hot tea and it left her right upper arm red and warm. The report also reflected DM-A contacted the company for the hot water dispensing machine to lower the temperature. The report was completed by the DON.Review of Resident #1's weekly skin assessment on 12/11/2025 reflected burns assessed on her right shoulder, right side of chest, right elbow, right antecubital (elbow) and right armpit. Report was completed by the DON.Review of Resident #1's orders reflected the following treatment:An order on 12/12/2025 for Silver Sulfadiazine Cream -apply to right upper arm, hip burn twice daily until heeled.Review of Resident #1's Discharge Summary on 12/15/2025 reflected she had exhibited progressive decline and diagnoses listed were heart failure and chronic kidney disease.Observation on 1/5/26 at 11:50 AM revealed the kitchen temperature monitoring log on hot liquids reflected the coffee being served on the drink station was 171 degrees F when it left the kitchen. Observation (tested) of the coffee in the large serving decanter on the drink station that was about to be served to residents had a temperature of 153.1 degrees F.Observation on 1/5/26 at 12:43 PM of the coffee from the large serving decanter on the drink station revealed the coffee was at 143.1 degrees F. Residents were actively drinking coffee in insulated cups and eating lunch in the dining room at that time.In an interview on 1/5/26 at 12:12 PM CK-A stated, logs were being kept on all hot liquids going to residents. She stated the maximum temperature allowed to serve hot liquids at was 165 degrees F. She stated they started monitoring the temperatures on 12/11/25 after Resident #1 was burned.In an interview on 1/5/26 at 1:19 PM DM-A stated they gave in-services to the kitchen staff on serving hot liquids. She stated that residents did not like hot liquids below 150 degrees F; -they said it was too cold. She stated that all residents were assessed for safety handling of hot liquids and all liquids were served in insulated cups with lids. She stated that when she went to Resident #1's room after the tea spilled, the resident stated she thought it was too hot so she took the lid off to allow the drink to cool. She stated there were burns on the right side of the resident. She stated that she was not familiar with the Hot Liquid Policy and did not know what it stated for maximum serving temperature. She stated water was heated up to 140 degrees F but if the resident requested it to be reheated, they could go up to 150 degrees F and the staff were aware of that.In a second interview on 1/5/26 at 1:58 PM CK-A stated she thought the maximum serving temperature was 165 degrees F, but she had just learned from DM-A that the maximum temperature was 150 degrees F. She stated that she had been in-serviced on the Hot Liquid Policy, but she did not remember what the policy said for the maximum temperature. She stated she was not concerned that the coffee carafe had been 153 degrees F since it was only 3 degrees above 150 degrees F. She stated the maximum temperature she would send hot liquids to a resident's room was 145-149 degrees F. She stated they were monitoring and logging the temperatures that left the kitchen so residents did not get hurt and accidents did not happen where they got burned. When asked why the monitoring log showed multiple days where liquids left the kitchen at temperatures as high as 171 degrees F, she did not know why. She stated it wasn't her initials on the log.In an interview on 1/5/26 at 2:43 PM DA-A stated she checked the temperature of the liquids going out to the residents. She stated she was in-serviced recently on hot liquid safety. She stated the maximum temperature for liquids to be served to residents was 150 degrees F. She stated if the liquid tested 170 degrees F, she would wait for it to cool to 150 degrees F to serve it. She stated that she did not record any temperatures checked after the initial check. She stated that monitoring the liquid temperatures was important to prevent residents from getting burns and that burns could cause scarring or infections and would hurt badly. She stated that she thought the coffee she checked for the carafe on the lunch drink station was 175nd that was her final check on it. She stated the temperature did worry her, but she noticed it came out at a different temperature.In an interview on 1/5/26 at 5:01 PM DT-A stated the maximum temperature to serve hot liquids was probably between 130-150 degrees F. She then stated the maximum temperature to serve would be 150 degrees F in a covered cup. She stated she was pretty sure they were serving in that range but not sure of what the policy was. She stated the temperature monitoring log was the responsibility of DM-A and she had not looked at the log. She stated she could not remember if the temperature to hold liquids was 150- or 160-degrees F. She stated it was important to monitor the temperature to stay out of the danger zone. She stated if liquids were not monitored, the residents could get liquids too hot and be burned. She stated her and the DM-A would get the best temperature figured out and would update the policy when they did. In an interview on 1/5/26 at 6:01 PM DM-A stated the log in the kitchen for hot liquids was her idea and her responsibility to monitor.In an interview on 1/5/26 at 6:14 PM the DON stated they did resident hot liquid assessments periodically and determined who was safe with hot liquids. She said they no longer were using the hot water machine, but they were using it when Resident #1 was burned. She stated the machine showed the water was 200 degrees F but they measured the temperature of the water as it came out and the water was 169 degrees F. They could not lower the temperature, so they took the machine out of service and changed to the insulated coffee carafe for serving. She stated kitchen staff were in-serviced on hot liquid safety. She stated it was important to monitor the temperatures to prevent burns on residents and she thought the DM-A was monitoring the temperature readings on the log.In an interview on 1/5/26 at 6:39 PM ADM-A stated after Resident #1 was burned, the facility started immediate in-services for kitchen staff on burns, liquid temperatures, and safe serving. The in-services had policies attached. She stated they removed the hot water dispensing machine. She stated it was important to monitor the temperature for resident safety to prevent burns. She stated what failed was continuous monitoring and daily monitoring. She stated she had assumed the log was being monitored by the DM-A.Record review on 1/5/26 at 2:10 PM of kitchen Hot Water Temperature Log revealed the following temperatures recorded leaving the kitchen:12/11/25 4 readings between 169-170 degrees F.12/12/25 2 readings between 152-156 degrees F.The log was revised starting 12/29/25 which reflected a temp column labeled, Temp Going Out12/29/25 2 readings above 150 degrees F.12/30/25 revealed the highest temperature recorded was for hot tea at 183.2 degrees F.12/31/25 revealed the highest temperature recorded was for hot tea at 188.6 degrees F.1/1/26 revealed the highest temperature recorded was for hot tea at 178.9 degrees F.1/2/26 revealed the highest temperature recorded was for coffee at 166.3 degrees F.1/3/26 revealed the highest temperature recorded was for hot tea at 156.4 degrees F.1/4/26 revealed the highest temperature recorded was for coffee at 169.4 degrees F.1/5/26 revealed the highest temperature recorded was for outside bar coffee at 171.6 degrees F.Record review of facility's undated temperature policy titled, Hot Beverage Preparation & Burn Safety Policy reflected:Hot beverages shall never exceed 140 degrees F at the point of service.Coffee was brewed at 195-205 degrees F. Transferred to an insulated carafe. Allowed to cool. Maintained above 135 degrees F but not exceeding 140 degrees F.Approved service temperature was 135-140 degrees F.Beverages exceeding 140 degrees F must not be served and must be cooled prior to service.