Legacy Nursing at St. Christina

Inspectors wroteBased on record review and interview, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was developed, implemented, and/or maintained in an effective and comprehensive manner. The facility failed to maintain documentation of its ongoing QAPI program. This deficient practice has the potential to affect 131 residents residing in the facility. Review of facility undated policy titled QAPI Policy and Procedure revealed in part. the facility shall develop, implement, and maintain ongoing, facility wide Quality Assurance and Performance (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals. Procedure: [...]

Inspectors wroteBased on record review and interview, the facility failed to provide documentation of the Quality Assurance and Performance Improvement (QAPI) program that addresses the facility's performance improvement activities and projects. The facility failed to provide evidence of the number and frequency of improvement projects conducted. This deficient practice had the potential to affect 131 residents residing in the facility. The facility was unable to present any documented evidence of activities, projects, or the frequency of improvement projects addressing services for the Quality Assurance and Performance Improvement (QAPI) program during the survey. In an interview on 02/24/2026 at 4:30 p.m. with S1 DON, S2 ADM, and S17 Regional, it was revealed that the facility is unable to locate its QAPI binder, which contains the facility's documentation and evidence of its ongoing QAPI program. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life by failing to:1. Ensure all residents seated at the same table were served simultaneously during dining service.2. Ensure Resident #100 was served his meal tray in his room at the same time of his roommate. Total sample size:

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered plan of care for each resident and ensure that care and services were furnished to attain the resident's highest practicable physical, mental, and psychosocial needs that were identified in the comprehensive assessment for 4 (Resident #10, #32, #80, and #90) of 56 sampled residents by the facility failing to:1. Provide a fall mat as care planned for Resident #90,2. Develop and implement a plan of care related to the activity of daily living (ADL) needs for Resident #32, 3. Provide a splint for a left hand contracture for Resident #80 as care planned.4. Develop and implement a care plan related to Resident #10's nebulizer treatments. Review of facility undated policy titled, Care Planning Policy and Procedure, revealed in part. Purpose: [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing: 1. To accurately assess and document the presence of skin tears for Resident #682. To ensure Physician's Orders were implemented for Resident #100. Review of a facility policy titled, Skin/Wound Documentation Policy and Procedure with no review date, read in part. Policy: Skin and wounds will be documented upon admission, readmission, weekly and as needed. Review of Resident #68's medical record revealed an admit date of 12/23/2025 with diagnoses that included in part. Review of Resident #68's medical record revealed an admission date of 12/23/2025 with diagnoses that included in part. Hypertension, Neuroleptic Induced Parkinsonism, Protein-Calorie Malnutrition, and Generalized Anxiety Disorder. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure menus were followed in order to meet the nutritional needs of residents who required a puree diet. The facility failed to follow the menu to ensure the nutritional adequacy of the meal for all 6 residents who received a puree diet.

Inspectors wroteNumber of residents sampled: Number of residents cited: Review of a facility policy titled Advance Directives Policy and Procedure, with no review date read in part. Procedure: 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. Review of Resident #68's medical record revealed an admission date of 12/23/2025 with diagnoses that included in part. Hypertension, Neuroleptic Induced Parkinsonism, Protein-Calorie Malnutrition, and Generalized Anxiety Disorder. Review of Resident #68's medical record on 02/22/2026 at 2:23 p.m. revealed Resident #68's 02/2026 Physician Orders read in part. order dated 01/16/2026-LaPOST-DNR (Do Not Resuscitate). Review of Resident #68's Care Plan with a Target Date of 04/11/2026 revealed in part . I have and advance directive-Full Code with interventions that included in part. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene by failing to provide assistance with bathing for 1 (Resident #113) of 5 residents reviewed for ADLs.

Inspectors wroteNumber of residents sampled: Number of residents cited: Review of a facility policy titled Oxygen Concentrator Cleaning Policy and Procedure, with no review date read in part. Procedure:Store Oxygen tubing, cannula, and mask in plastic bag when not in use. Oxygen tubing, cannula and mask to be changed weekly and as needed. Review of Resident #10's medical record revealed an admit date of 01/02/2025 with diagnoses which included in part. Anemia, Parkinson's Disease without Dyskinesia, Other Specified symptoms and signs involving the Circulatory and Respiratory Systems and Personal History of Pneumonia. Review of Resident #10's Physician Orders dated 02/2026 revealed in part. Ipratropium-Albuterol Inhalation Solution (breathing treatment) 0.5-2.5 (3) MG/3ML. [...]

Inspectors wroteFindings:Review of Resident #9's medical record revealed an admit date of 10/25/2025.with diagnoses that included in part. Paraplegia, Chronic Obstructive Pulmonary Disease (COPD), Essential Hypertension, and Neuromuscular Dysfunction of Bladder. Review of the Resident #9's Quarterly MDS with an ARD of 02/03/2026 revealed the following:Section K - Swallowing/Nutritional Status - The resident was on a therapeutic diet. Review of Resident #9's physician orders dated 10/25/2025 revealed an order for NAS (no added salt) diet, Regular texture, Regular-Thin consistency. Double meat, paper tray set up. Review of Resident #9's care plan revealed in part. Intervention: I need my diet served to me as ordered.1. On 02/23/2026 at 1:08 p.m., Interview and Observation of Resident #9's lunch meal ticket revealed diet of NAS, texture regular, fluid thin liquids, with no note for double meat. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store, prepare, and serve food in accordance with professional standards for food service safety. The facility failed to ensure that kitchen staff were wearing hair restraints including beard restraints to prevent hair from contacting food. The deficient practice had the potential to affect all of the residents who received meals from the kitchen. There were 131 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Quality Assessment and Assurance committee met at least quarterly to identify facility issues and coordinate and evaluate performance improvement projects. A review of the facility's Quality Assurance binder revealed that the last documented Quality Assurance (QA) meeting was held on 10/15/2025 for the 2025 3rd quarter (July-September). In an interview on 02/24/2026 at 4:33 p.m., S2 ADM stated that the QAA committee did have a meeting for the 2025 4th quarter, and the documented meeting minutes were located in the QAPI (Quality Assurance and Performance Improvement Program) binder, which the facility cannot locate. S2 ADM stated he had no documented evidence of the QAA committee meeting for the 2025 4th quarter.

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control environment by failing to ensure the facility was free from insects. The deficient practice had the potential to affect all 131 residents who resided in the facility.

Inspectors wroteA review of the facility's undated policy titled, Quality of Care Policy and Procedure, read in part. It is the policy of our company that each resident receives the necessary care to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the resident's comprehensive assessment and plan of care. Resident #1Review of Resident #1's medical record revealed an admission date of 10/06/2022, with diagnoses that included, in part. Chronic Obstructive Pulmonary Disease, Type II Diabetes, and Benign Prostatic Hyperplasia with lower urinary tract symptoms, Obstructive and Reflux Uropathy. Review of Resident #1's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/30/2025 revealed Resident #1 had a BIMS score of 14, which indicated intact cognition. Resident #1 required moderate assistance with showering and bathing. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that an allegation of verbal abuse was reported immediately, but no later than 2 hours after the allegation was made, to the State Survey Agency for 1 (Resident #1) of 3 sampled residents reviewed for abuse. Review of the facility's undated policy titled, Abuse Reporting and Investigation Policy and Procedure, read in part. 2. An Alleged violation of abuse, neglect, exploitation, or mistreatment will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury. Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance or sight, regardless of age, ability to comprehend, or disability. Examples: [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse for 1 (Resident #2) of 4 (Resident #1, Resident #2, Resident #3, Resident #4) sampled residents. This deficient practice resulted in Actual Harm for Resident #2 on 09/21/2025 at 3:30 pm, when Resident #2 was hit by Resident #4 in the face with his left fist. Resident #2 was sent to a local emergency department where he received treatment for a facial contusion.

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of staff to resident sexual abuse and resident to resident physical abuse was reported to the State Survey Agency immediately, but not later than 2 hours after the staff to resident sexual abuse and resident to resident physical abuse was discovered, for 2 (Resident #1 and Resident #2) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure services were provided to meet professional standards of practice by failing to ensure a residents received a prescribed antibiotic in a timely manner for 1 (#2) of 3 (#1, #2, and #3) sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident received enteral feedings as ordered by the physician for 1 (#3) of 3 (#1, #2, and #3) sampled residents.

Inspectors wroteBased on a record review and interview, the facility failed to provide care and services that met professional standards of quality by failing to ensure that a resident's medical record reflected whether Physician's Orders were implemented or refused. The facility failed to document whether wound care was or was not provided for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) residents reviewed for skin and pressure ulcers. Review of facility undated policy titled, Skin/Wound Documentation Policy and Procedure, revealed in part. Skin and wounds will be documented upon admission, readmission, weekly, and as needed. The facility shall follow the practitioner's orders for treatment of the pressure ulcer (injury). With each dressing change, or at least weekly, the pressure ulcer (injury) wound shall be assessed and documented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain personal hygiene for 1 (Resident #3) of 3(Resident #1, Resident #2, Resident #3) residents reviewed for Activities of Daily Living (ADL) care. The facility failed to ensure a Bath/Shower was provided for Resident #3. A review of facility undated policy titled, Quality of Care Policy and Procedure, read in part. It is the policy of our company that each resident receives the necessary care to attain or maintain the highest practicable physical, mental and psychological well-being, in accordance with the resident's comprehensive assessment and plan of care. Review of Resident #3's medical record revealed an admit date of 03/10/2025 with the following diagnoses in part. [...]

Inspectors wroteBased on observation and interview the facility failed to maintain housekeeping and maintenance services necessary to maintain a sanitary and orderly interior. This deficient practice had the potential to affect the 124 resident's that resided at the facility.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide care and services that meet professional standards of quality, by failing to: 1. Perform weights as ordered for 3 (#3, #4, and #R1) of 6 (#1, #2, #3, #4, #R1, and #R2) residents reviewed for weights; and 2. Input orders for wound care for 1 (#4) of 3 (#2, #3, and #4) residents reviewed for wound care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received reasonable accommodation of needs for 2 (#3 and #4) of 4 (#1, #2, #3, and #4) sampled residents. The facility failed to ensure Resident #3 and Resident #4 had an appropriate call light and that it was within reach to call for assistance.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure 1 (Resident #3) of 2 ( Resident #3 and Resident #4) sampled residents received the necessary treatment and services to prevent and promote the healing of pressure ulcers by failing to perform hand hygiene during treatment of a pressure ulcer.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure each resident was free of medication errors for 1 (#4) of 4 residents reviewed. The facility failed to ensure medications were administered to Resident #4 as ordered by the physician.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and the resident's person centered plan of care, for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) residents sampled for quality of care. This deficient practice resulted in a delay in treatment of a wound to Resident #3's right elbow, and development of cellulitis of the right elbow that required antibiotic treatment. This failed practice resulted in an actual harm for Resident #3 on 02/26/2025 at 2:26 p.m., when the resident was observed to have a wound to his right elbow, with edema and erythema noted. On 02/21/2025 at 11:38 p.m., Resident #3 sustained a 1cm x 1cm skin tear to the right elbow as a result of a fall, and first aid was administered at that time. [...]

Inspectors wroteBased on interviews, and record reviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices. The facility failed to ensure: 1. A wound care order was documented for Resident #3 when received by facility; 2. Documentation on the Treatment Administration Report (TAR) was accurate for Resident #3; and 3. Wound care was documented for Resident #3.

Inspectors wroteBased on interview and record review the facility failed to ensure services were provided according to the residents plan of care for 2 (#33 and #91) out of a sample of 40 residents. The facility failed to follow the following physician's orders for monthly labs for Resident #33 and failed to ensure wound care was provided for Resident #91 as ordered.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a clean, safe, comfortable and homelike environment by failing to ensure the cleanliness and good repair of patient care equipment for 2 (Resident #52 and Resident #39) of 40 total sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to transmit/encode a Discharge MDS (Minimum Data Set) Assessment accurately for 1 (Resident #100) of 1 sampled resident reviewed for resident assessments. The total sample size was 40 residents.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure physician's orders were implemented as ordered. The facility failed to ensure the correct tube feeding was administered at a continuous rate for 1 (#67) of 1 residents reviewed for tube feeding. Total sample size was 40.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary service to maintain good nutrition for 1 (Resident #52) resident reviewed during dining services in a total of 40 sampled residents. The facility failed to provide assistance during meal time to Resident #52.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff followed a resident's person centered plan of care, by failing to use 2-person physical assistance when transferring a resident from wheelchair to bed for 1 (Resident #55) of 3 (Resident #55, Resident #79, and Resident #251) residents reviewed for accidents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 2 (Resident #67 and Resident #81) of 4 sampled Residents reviewed for respiratory care. The facility failed to ensure equipment was properly labeled and stored. Total sample size was 40.

Inspectors wroteBased on record review and interview the facility failed to ensure there was sufficient nursing staff available at all times to provide nursing and related services to meet the resident's needs and safety in a manner that promotes each residents rights, physical, mental and psychosocial well-being. The facility failed to ensure there was sufficient staff on Saturday 09/28/2024, to provide care and services for residents residing in the facility. The facility census was 96.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident's right to be free from physical abuse by another resident for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to protect Resident #1 from being punched and kicked by Resident #2 on 09/18/2024, and pushed down on the ground by Resident #2 on 10/04/2024. This failed practice resulted in an actual harm situation for Resident #1 on 09/18/2024 at 3:00 p.m., when a CNA reported Resident #1 was on the floor after wandering into Resident #2's room, and Resident #2 was kicking Resident #1 in the chest and abdominal areas with bare feet; and on 10/04/2024 at approximately 3:50 p.m., when Resident #2 pushed Resident #1 from behind, causing him to fall to the floor face first. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of resident to resident abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of staff to resident physical abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to have evidence that an allegation of staff to resident physical abuse was thoroughly investigated for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #1), of 3 sampled residents (#1, #2, and #3). The facility failed to ensure Resident #1 was not hit in the face by Resident #2. This failed practice resulted in an Actual Harm situation for Resident #1 on 01/31/2024 at 8:50 p.m. Resident #1 wandered into Resident #2's room, and Resident #2 hit Resident #1 in the face. Resident #1's right eye was red and slightly swollen immediately after the incident. On 02/01/2024 at approximately 8:00 a.m., staff noted Resident #1's eye to have increased swelling and discoloration. Resident #1 was transferred via ambulance to a local emergency room on [DATE] at 8:30 a.m. Review of a Radiology Report dated 02/01/2024 at 10:00 a.m. revealed Impression: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was immediately notified when there was a significant change in a resident's physical health, for 1 (#1) of 3 sampled residents (#1, #2 and #3). This failed practice resulted in an actual harm situation for Resident #1 on 12/22/2023 at approximately 8:45 a.m., when Resident #1 was observed by S8 CNA to have difficulty walking, and was unable to feed himself. S4 LPN was notified; however, S4 LPN did not notify Resident #1's physician. At 2:00 p.m., S8 CNA reported Resident #1's condition to S1 Administrator. Resident #1 was sent to the hospital, and underwent a left Frontoparietal Epidural Hematoma Evacuation on 12/23/2023.

Inspectors wroteBased on interview and record review the facility failed to ensure a residents' rights to be free from staff to resident physical abuse, for 1 (Resident #1), of 3 sampled residents (#1, #2, and #3). The facility failed to ensure Resident #1 was not pushed by S5 CNA, while S5 CNA was in the process of intervening during an aggressive act by another resident. This failed practice resulted in an Actual Harm situation for Resident #1 on 12/14/2023 at 4:19 p.m. Resident #1 was pushed by S5 CNA in the dayroom of Hall A, while S5 CNA intervened in an incident that involved Resident #2 and S6 CNA. S5 CNA intervened when Resident #2 grabbed S6 CNA's shirt. S5 CNA pushed Resident #1 during the intervention, and Resident #1 fell and hit his head on a tiled floor. Resident #1 was transferred via ambulance to a local emergency room on [DATE] at 6:39 p.m. The ER record revealed: Primary Impression: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents' rights to be free from resident to resident physical abuse. The facility failed to ensure 1 (Resident #18) of 4 (Resident #18, Resident #313, Resident #314, and Resident #363) sampled residents for abuse were not physically abused. This deficient practice resulted in an Actual Harm for Resident #18 that began on 06/18/2023 at 9:40 p.m. when Resident #363 threw the arm of his wheelchair at Resident #18 striking him on the left side of the face. Resident #18 received first-aid treatment in the facility for a laceration to the left face and was sent to a local ED where Resident #18 received three sutures to the left face laceration. Resident #18 continued to complain of pain to the left eye and was referred to ophthalmology on 07/13/2023, when it was determined Resident #18 would require eye surgery. [...]

Inspectors wroteBased on interview and record review, the facility failed to act promptly on grievances concerning issues of resident care and life in the facility reported by residents during a monthly Resident Council meeting for 1 (10/30/2023) of 3 (08/28/2023, 09/26/2023, and 10/30/2023) meetings reviewed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure services were provided to meet professional standards of practice for 3 (Resident #70, Resident #80, and Resident #90) of 37 sampled residents. The facility failed to ensure: 1. A resident's peg tube was checked for placement and residual prior to beginning a feeding as ordered for Resident #70, 2. Physician's orders for peg tube feedings were followed for Resident #80, and 3. Physician's orders for documenting percentages of Mighty Shake and House Supplement were followed for Resident #90.

Inspectors wroteBased on record review and interview, the facility failed to ensure the facility had 8 consecutive hours per day of Registered Nurse (RN) coverage for 4 of 91 days reviewed for RN hours.

Inspectors wroteBased on record review and interview, the facility failed to complete an annual performance review of every nurse aide at least once every 12 months for 5 (S5 CNA, S6 CNA, S7 CNA, S8 CNA, and S9 CNA) of 5 CNA personnel records reviewed.

Inspectors wroteBased on observation and interview the facility failed to ensure garbage and refuse were disposed of properly. This deficient practice had the potential to affect all 119 residents who resided in the facility.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #101) of 1 residents sampled for dignity. The facility failed to ensure Resident #101 was dressed in appropriate footwear.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 (Resident #45 and Resident #66) residents by failing to ensure the floor was in good repair for Room A; and by failing to ensure a residents clothes were stored properly off the floor. Total sample size was 37.

Inspectors wroteBased on interview and record review the facility failed to ensure their grievance policy and procedure was followed by failing to ensure prompt investigation of an allegation and to provide a written resolution of a resident's complaint/grievance for 1 (Resident #29) resident of 37 sampled residents.

Inspectors wroteBased on record review and interview the facility failed to ensure a reportable incident was reported to the State Agency for 1 (#18) of 3 (#18, #108, #313) residents reviewed for incidents and accidents. The facility failed to report an incidence of resident to resident abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person centered plan of care consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #55) of 37 sampled residents. The facility failed to include in Resident #55's care plan the need for staff assistance with ADLs.

Inspectors wroteBased on interview and record review, the facility failed to revise a comprehensive person-centered care plan for 1 (Resident #78) of 37 sampled residents, by failing to reflect Resident #78 required increased supervision due to wandering behavior.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 (Resident #19, Resident #77, and Resident #90) of 5 (Resident #19, Resident #31, Resident #55, Resident #77, and Resident #90) residents investigated for activities of daily living out of a total sample of 37 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident received adequate supervision to prevent accidents and incidents for 1 (#363) of 3 (#18, #108, and #363) sampled residents for incidents and accidents. The facility failed to ensure Resident #363 received increased supervision after inflicting injury upon Resident #18.

Inspectors wroteBased on observation and interview the facility failed to ensure that food was stored in accordance with professional standards for food service. The facility failed to ensure that expired/outdated items were not available for resident consumption. This deficient practice had the potential to affect all residents that received meals prepared by the kitchen.

Inspectors wroteBased on interview and record review the facility failed to ensure resident's responsible party (RP) was notified of an unplanned discharge and a significant change in physical, mental, or psychosocial status for 2 (#1, #2) of 3 (#1, #2, #3) residents reviewed for notification of change. The facility failed to: 1. Notify Resident #1's RP of his unplanned discharge from the facility. 2. Notify Resident #2's RP of a significant change in her condition that required a transfer to the hospital.