George L Mee Memorial Hospital D/P SNF

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide and served food at an appropriate temperature. This failure placed the 40 residents eating at the facility at risk of poor food intake further compromising their nutritional status.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food safety when:1. The kitchen dry storage room temperature was not checked in the afternoon from 1/1 to 1/15/2026 and no logged temperature check from 1/16/2026 - 1/20/2026, as indicated in their dry storage temperature log;2. The box of lemons stored in the walk-in refrigerator had one lemon covered with whitish substance mixed with other lemons;3. The staff personal purse was stored in the clean plate storage rack;4. The black storage rack for plastic cups, clean plates and metal food containers had some dust like substances and food crumbs; and5. Food service worker K (FSW K) kept on touching her eyeglasses while mixing the batter of an apple sauce bar without changing gloves and performing hand hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three out of four residents (Residents 25, 9, and 1) were free from chemical restraints (the use of medications such as psychotropic medications [drugs that affects brain activities associated with mental processes and behaviors, example is antipsychotics, antidepressants, anti-anxiety, hypnotics] not for therapeutic reasons, but to restrict a person's freedom of movement or control their behavior) when:1. Resident 25 continued to receive quetiapine (brand name is Seroquel - an antipsychotic [AP] medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought], bipolar disorder [sometimes called manic-depressive disorder; [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment for two of 12 sampled residents (Resident 9 and Resident 5) when:1. Resident 9's quarterly MDS assessment dated [DATE] did not reflect her actual pressure injuries (PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence)at the time of assessment; and2. Resident 5's admission MDS assessment dated [DATE] did not reflect the actual pressure injuries he was admitted with. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure care and services were provided to meet the professional standards of practice for seven of 12 sampled residents (Residents 22, 9, 34, 2, 3, 4, 35 and 21) when:1. Resident 22 had no care plan developed for used of apixaban (brand name: Eliquis, an anticoagulant drug known as blood thinners, prevent or reduce the formation of harmful blood clots in blood vessels);2. Resident 9 had no care plans developed for used of quetiapine (brand name is Seroquel - an antipsychotic medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought], bipolar disorder [sometimes called manic-depressive disorder; [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their Leave of Absence (LOA) policy and procedures (PnP) for two of 45 residents (Resident 20 and 45) when licensed nurses (LN) did not complete and document Resident 20 and 45's mental, physical, and functional assessments prior to leaving and upon returning to the facility. This failure could potentially compromise Resident 20 and 45's safety and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications was followed according to the facility's policy and procedures (P&P) and/or manufacturer's specifications when: 1. One vials of tuberculin purified protein (Aplisol- a sterile aqueous solution of purified protein fraction for intradermal administration used in the diagnoses of tuberculosis) with expired date of [DATE]; 2. One vial of Admelog (insulin -lispro-a fast-acting mealtime insulin that helps to control blood sugar was expired on [DATE]; 3. A bottle of Latanoprost 0.005% (used to treat glaucoma [a condition in which increased pressure in the eye can lead to gradual loss of vision]) eye drop was open and undated. 4. A bottle of latanoprost 0.005% was identified inside a box unopened with seal and on the box label refrigerate until open. 5. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure resident's foods brought from home were stored in a safe and sanitary manner, when one refrigerator with built in freezer designated for residents have perishable food (likely to spoil, decay or become unsafe to consume) that were not dated and discarded. This failure had the potential for the contamination of residents' food.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices when:1. Resident room with enhanced barrier precaution (EBP - infection control measures that involve using gowns and gloves during high-contact resident care activities, in addition to standard precautions) signage did not have isolation cart;2. Licensed Vocation Nurse (LVN) did not follow the proper sequence of wearing Personal Protective Equipment (PPE) and touches LVN face area with clean gloves, did not clean the overbed table (an adjustable table designed to roll over a bed and provide a flat and stable surface) without placing a barrier first (such as a clean paper towel) before placing then glucometer (a portable device used to measure the concentration of glucose in the blood) and insulin syringe (a sterile , single -use device for injecting insulin);3. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer and administer pneumococcal vaccine (PV, immunization against bacteria that causes pneumonia [a lung infection]) for three of five sampled residents (Resident 3, 5,and 20,) requiring PV vaccines, and Resident 5's missing Flu vaccine (an annual seasonal flu vaccine is the best way to help reduce the risk of getting flu and any of its potentially serious complications) in accordance with the current Centers for Disease Control and Prevention (CDC) recommendations. This failure had the potential to compromise the resident's health.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect a resident's rights to confidentiality of protected health information (PHI, any information in the medical record that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment) for two of 12 residents' (Residents 3, and 40) clinical records, when Licensed Vocational Nurse (LVN) F computer screen was left open and unattended in the hallway near residents 3 and 40's room during medication pass. These failures had the potential to result in unauthorized access to the resident's health information. Findings 1a. During a medication administration observation on 1/22/26, at 11: 28 a.m., the Med cart CC containing an open laptop computer was left unattended in the hallway outside of Resident 40's room. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident receiving dialysis (removal of waste and excess fluid from the body) treatment received care consistent with professional standards for one of 12 sampled residents (Resident 7) when the nursing facility/dialysis unit communication reports (NF/DUCR) were incomplete. This deficient practice had the potential for Resident 7's dialysis care not being properly communicated and could put Resident 7 at risk for complications.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the controlled substance (drugs with high potential for abuse or addiction) medications were fully accounted for on the electronic medication administration record (eMAR) to indicate they were given for one out of four residents (Residents 29) showed that medications were signed out of the Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications). This failure had the potential for access to medications and supplies by unauthorized persons such as residents and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food and nutrition services staff carried out the functions of food and nutrition service competently according to facility policy and standards of practice when: 1. Two kitchen staff were unable to properly test the dish machine sanitizer solution concentration. 2. Kitchen staff did not correctly verbalize the cool down process for cooked foods. 3. Kitchen staff did not wash melons prior to cutting. These failures had the potential to expose residents to bacterial contamination, that can result in food borne illnesses for all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety and sanitation methods were followed according to standards of practice and facility policy when: 1. The ice machine had visible pink slime and tan colored residue on the ice making parts. 2. Two drainage pipes did not have air gaps. 3. Three floor sink drains were visibly dirty with dark black and brown stains, crumbs, and food debris. 4. Expired sliced cheese, sliced pears, and cranberry juice were found in the reach-in and walk-in refrigerators. 5. [NAME] bell peppers had grayish and black spots resembling mold in the walk-in refrigerator. 6. Metal shelves on a dish drying rack and inside the walk-in refrigerator were rust. 7. A reach-in freezer door gasket was dirty with black and brown sticky grime and residue. 8. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) for an advance directives (AD, a written instruction for healthcare when the individual is incapacitated) and for completion of physician orders for life-sustaining treatment (POLST, a document that specifies the medical treatments the resident wants to receive during serious illness) form for 7 of 8 sampled residents (Residents 9, 22, 24, 26, 31, 32, and 184). These failures have the potential for delivery of medical services against residents' wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive, resident-centered care plans for six out of thirteen sampled residents (Residents 15, 8, 3, 5, 1, and 29), when the activity care plans of Residents 15, 8, 3, 5, 1, and 29, were not comprehensive and resident-centered. These failures had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure approved menus were followed and emergency menus were developed to properly feed residents in an emergency. These failures had the potential for the facility to not meeting Residents' nutritional needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure food was prepared in a manner which conserved flavor and nutritive value when hot foods were served cold and cold foods were served hot, and when pureed food recipes was not followed, which resulted in lumpy foods for three residents. These deficient practices had the potential to decrease the food intake of residents and negatively impact their nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity for 2 of 3 sampled Residents (Residents 31 and 32) when Residents 31 and Resident 32's foley catheter (F/C, a semi-flexible plastic tube, inserted into a person's urinary bladder [a body organ that stores urine] one end and the other end attached to a bag that collects urine) drain bags were left uncovered. This failures had the potential to negatively affect the psychosocial well-being and health of Residents 31 and 32.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and procedure (P&P) for oxygen (gas that supports life) therapy for 1 of 3 sampled residents (Resident 31), when oxygen was administered to Resident 31 without a physician's order for it. This failure resulted in Resident 31 receiving oxygen without a physician's order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to accommodate food dislikes and preferences for one out of three sampled resident (Resident 30). This failure had the potential for negative effects on health secondary to decreased food intake for Resident 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement proper infection prevention and control practices for one out of five residents observed for medication administration, (Resident 16), when the registered nurse did not perform hand hygiene; such that, after throwing used gloves in the trash bin, she proceeded to prepare medications of Resident 16. This failure had the potential to spread infections, and compromise residents' health and safety in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored and prepared in accordance with professional standards for food safety when: 1. Undated food, food past their used-by date, and rotten lettuce were found in the refrigerators and on the shelves in the kitchen; 2. Dietary Aid A (DA A) did not cover his beard with a hair net; and, 3. [NAME] B (CK B) did not cover the hair in the back of her head in a hair net. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness and cross-contaminated food for the 31 residents eating at the facility.

Inspectors wroteBased on observation and interview, the facility failed to store medications appropriately when: 1. Two of three medication carts were left unlocked and unattended; and 2. Residents 9's sevelamer (medication used to control high blood levels of phosphorus in people with chronic kidney disease) 800 milligrams (mg, a metric unit of mass) was left on the medication cart unattended. These failures had the potential to result in the access of medications by unauthorized personnel or residents.

Inspectors wroteBased on observation, interview, and record review, the facility had a 16% error rate when four medication errors out of 25 opportunities were observed during a medication pass for 3 of 14 residents (16, 17, and 31). These failures resulted in medications not given in accordance with prescriber's orders, which had the potential for residents to not receiving the full therapeutic effect of the medications (in the case of underdosing) or had the potential to for preventable side effects for the residents (in the case of overdosing).

Inspectors wroteBased on observation and interview, the facility failed to ensure: 1. Two expired medications and 46 expired 8-oz boxes of renal supplement were made unavailable for resident use; and, 2. Two opened multi-dose eye medications were dated with an open and discard date (to ensure they were not used beyond the discard date). These failures had potential for residents to receive medications with reduced potency from being used past their discard date.

Inspectors wroteBased on interview and record review, the facility failed to send a copy of Resident 35's notice of discharge to the Long Term Care Ombudsman. This failure had the potential of not providing Resident 35 with access to an advocate who could inform him of his options and rights and from being inappropriately discharged .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 12 residents (16) was free of a significant medication error when Resident 16 received insulin degludec (a long-acting insulin, medication to lower blood sugar level) nine times (doses) past the expiration date. This failure had the potential for ineffective use of the insulin (secondary to degraded potency of expired medication), resulting in uncontrolled high blood sugar for the resident.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify residents' representatives and families of those residing in the facility by 5 p.m., the next calendar day following the occurrence of a confirmed infection of COVID-19 (a respiratory disease caused by a virus which can result in severe illness and death) and scabies (an intensely itchy skin condition that spreads quickly through close physical contact) for two of 12 residents (14 and 16). These failures had the potential to result in residents' representatives and families, not receiving timely notification regarding the status and impact of COVID-19 and scabies in the facility.