Odin Health and Rehab Center

Inspectors wroteBased on interview and record review the facility failed to notify the physician for a resident's change in condition for 1 of 3 residents (R1) reviewed for changes in condition in a sample of 13. This failure resulted in R1's hospitalization for sepsis and subsequent death. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 10/5/25 when the facility staff failed to notify the physician that R1 had decreased urine output and oral intake, was refusing to eat, and appeared lethargic. On 10/7/25, R1 was found to have a worsened pressure ulcer and a sharp decline in R1's overall condition and was sent to the ER (Emergency Room). R1 expired on 10/8/25 with a cause of death of Sepsis.

Inspectors wroteBased on observation, interview, and record review the facility failed to recognize and assess the symptoms of a worsened pressure wound and provide and document wound treatments as ordered for 2 of 3 residents (R1, R3) reviewed for pressure ulcers in the sample of 13. This failure resulted in R1's sacral ulcer worsening and R1 being transferred to the hospital, where the wound was found to be infected with gram positive cocci and gram-negative bacilli.

Inspectors wroteBased on interview and record review, the facility failed to provide narcotic pain medication per physician orders for 2 of 3 (R1 and R3) residents reviewed for pain management in a sample of 3. This failure resulted in R1 and R3 experiencing unrelieved pain and having to be sent to the local hospital for treatment of pain. This past noncompliance occurred from [DATE] to [DATE].

Inspectors wroteBased on interview and record review the facility failed to obtain a new prescription for a controlled substance in a timely manner for 2 of 3 residents (R1 and R3) reviewed for pharmacy services in the sample of 3. This past noncompliance occurred from [DATE] to [DATE].

Inspectors wroteBased on interview and record review, the facility failed to provide narcotic pain medications per physician's orders for 1 (R1) of 3 residents reviewed for pain management in the sample of 5. This failure resulted in R1 experiencing unrelieved pain and having to be sent to the local hospital for treatment of pain. R1's admission Record documents that R1 is a [AGE] year-old that was admitted to the facility on [DATE]. Diagnoses included are unspecified fracture of right femur, cirrhosis of liver, pain due to internal orthopedic prosthetic device, pain in right hip, weakness, chronic kidney disease, anemia, and osteoarthritis of right knee. R1's MDS (Minimum Data Set) dated 06/16/2025, documented that R1 has a BIMS (Brief Interview for Mental Status) score of 15 indicating R1 is cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident received the correct medications in accordance with their physician's orders for 1 (R4) of 3 residents reviewed for medications in the sample of 5. This failure resulted in R4 having increased behaviors and being hospitalized for behaviors. R4's admission Record documents that R4 was admitted to the facility on [DATE]. Diagnoses listed are vascular dementia, type 2 diabetes mellitus, brief psychotic disorder, unspecified mood disorder, auditory hallucinations, schizophrenia, anxiety and unspecified psychosis. R4's MDS (Minimum Data Set) dated 03/26/2025, documents R4 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R4 is cognitively intact. R4's Care Plan with a revision date of 5/7/24 documents a Focus area of This resident is on an antipsychotic. Documented interventions include: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from physical abuse for 1 (R4) of 3 residents reviewed for abuse in the sample of 5. R4's admission Record documents that R4 was admitted to the facility on [DATE]. Diagnoses listed are vascular dementia, type 2 diabetes mellitus, brief psychotic disorder, unspecified mood disorder, auditory hallucinations, schizophrenia, anxiety and unspecified psychosis. R4's MDS (Minimum Data Set) dated 03/26/2025, documents R4 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R4 is cognitively intact. R4's Care Plan with a revision date of 07/08/2025 has a focus are of, (R4) is at risk for decline in psychosocial well being related to: Allegation of abuse related to a resident-to-resident altercation. The interventions listed are: [...]

Inspectors wroteBased on interview and record review the facility failed to obtain a new prescription for a controlled substance in a timely manner for 1 of 3 residents (R1) reviewed for pharmacy services in the sample of 5. R1's admission Record documents that R1 is a [AGE] year-old that was admitted to the facility on [DATE]. Diagnoses included are unspecified fracture of right femur, cirrhosis of liver, pain die to internal orthopedic prosthetic device, pain in right hip, weakness, chronic kidney disease, anemia, and osteoarthritis of right knee. R1's MDS (Minimum Data Set) dated 06/16/2025, documented that R1 has a BIMS (Brief Interview for Mental Status) score of 15 indicating R1 is cognitively intact. R1's Care Plan with a revision date of 09/30/2024 has a focus are of The resident has chronic pain. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's representative of a hospital admission for 1 (R1) of 3 residents reviewed for notification of changes in the sample of 8.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide sanitary food service by not performing hand hygiene. This failure has the potential to affect all 64 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to answer call lights timely and promote resident dignity during dining for 4 (R6, R19, R22, and R25) of 4 residents reviewed for resident rights in the sample of 46. Findings Include: 1. R25's admission Record documented an admission date of 5/5/2023 with diagnoses that included hemiplegia affecting left non dominant side, peripheral vascular disease and generalized anxiety among others. R25's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating R25 is cognitively intact. R25's MDS also documented he was dependent on staff for toileting, showering, dressing and transferring. On 5/6/2025 at 8:15AM, R25's call light was noted to already be activated. R25's call light remained activated until staff answered the call light at 9:00AM. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a clean and homelike environment for 2 (R49 and R54) of 4 residents reviewed for environment in a sample of 46.

Inspectors wroteBased on record review and interview, the facility failed to ensure that services were provided within the professional scope of practice when nursing staff administered and documented multiple medications late to 3 (R8, R23, and R37) of 5 residents reviewed for medication administration in a sample of 46.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure residents were assisted with activities of daily living (ADL's) in a timely manner for 3 (R6, R7, and R24) of 19 residents reviewed for ADL assistance in a sample of 46.

Inspectors wroteBased on interview and record review, the facility failed to implement new interventions to prevent falls for 2 (R27 and R63) of 4 residents reviewed for accidents/supervision in the sample of 46.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Transmission-Based Precautions were followed for 1 (R29) of 3 residents reviewed for Infection Prevention and Control in the sample of 46.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer pneumococcal immunizations as ordered by a physician for 2 (R2 and R21) of 5 residents reviewed for immunizations in the sample of 46. Findings Include: R2's admission record dated 05/13/25 documented an admission date of 06/16/22 and included diagnoses of Alzheimer's, unspecified atrial fibrillation, abnormal thyroid function, and thrombocytosis. R2's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) was not conducted as resident is rarely/never understood, and the staff assessment documented R2 has short- and long-term memory problems. R2's Care Plan with a revision date of 04/14/24 documented a Focus Area of Self-Care Deficit as Evidenced by: Needs assistance with ADL (Activities of Daily Living). [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide narcotic pain medications per physicians orders and failed to assess the effectiveness of non narcotic pain medication for 2 of 2 residents (R1, R3) reviewed for pain management in the sample of 14. This failure lead to R1 and R3 experiencing unrelieved pain up to 9 and 10 on a scale of zero to ten.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate direct care CNA (Certified Nursing Assistant) staffing. This has the ability to affect all 66 residents living at the facility.

Inspectors wroteBased on interview and record review, the facility failed to support resident dignity by the timely answering of call lights for 5 residents (R1, R2, R3, R12, R14) of 14 residents reviewed for dignity in the sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to provide twice weekly showers for three residents (R3, R12, R14) of 14 residents reviewed for Activities of Daily Living in the sample of 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medications per physicians orders for three residents (R1, R3, R11) of 14 residents reviewed for medication orders in the sample of 14.

Inspectors wroteBased on interview and record review the facility failed to implement a surveillance plan for tracking, monitoring, and reporting communicable diseases and outbreaks. This has the potential to affect all 71 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to answer resident call lights in a timely manner for 5 of 8 residents (R1, R2, R3, R4, R5) reviewed for call light response times in a sample of 8.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from abuse from staff for 1 of 3 residents (R2) reviewed for abuse and neglect in the sample of 10.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were properly stored at appropriate temperatures and in locked compartments. This failure has the potential to affect all 68 residents residing in the facility. Findings Include: On 06/26/24 at 09:00 AM, No temperature logs in the medication storage room for the medication and insulin refrigerators. On 06/26/24 at 09:00 AM, V2 (Director of Nursing/DON) stated, there were temperature logs for the medication and insulin refrigerators but is not sure where they are at. V2 stated she would need to ask V4 (Minimum Data Set Coordinator/MDS) if she knows where the temperature logs are. On 6/26/24 at 12:53 PM, V2 stated she is still unable to locate the medication refrigerator logs. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow policy and procedure for enhanced barrier precautions for 10 of 13 residents (R1, R5, R14, R18, R42, R60, R62, R65, R67, and R68) reviewed for infection control in the sample of 46. The Findings Include: On the initial tour of the facility on 06/25/2024 beginning at 9:30 AM, there were no resident rooms observed in the facility with signage on the doors indicating residents were on isolation or enhanced barrier precautions. On 06/25/2024 a Matrix for Providers (Form CMS 802) was provided by the facility with no residents marked for transmission-based precautions. On 06/25/24 at 11:36 A.M., V13 (Certified Nurse Assistant-CNA) was noted to be exiting the room of R67 and R68 from providing care. V13 stated she is not for sure who is on isolation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the MDS (Minimum Data Set) were accurately coded for 1 of 3 resident (R57) in the sample of 46. The Findings Include: Review of R57's admission Record documented R57 as a [AGE] year old female with an Initial admission Date to the facility as 03/02/2023. Diagnoses listed on this document are: unspecified dementia, Bipolar Disorder, hypotension, edema, anxiety, and venous insufficiency. R57's Preadmission Screening and Resident Review (PASRR) dated 06/28/2023 documented Level 1 outcome: Refer for Level II onsite. R57's Notice of PASRR level II Outcome dated 06/30/2023 documented a PASRR determination of Approved without Specialized Services. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide meal preferences for 2 of 2 residents (R14, R69) reviewed for meal preferences in the sample of 46 .

Inspectors wroteBased on observation, interview, and record review the facility failed to provide therapeutic diets as ordered for 1 of 3 residents (R42) reviewed for diets in the sample of 46. Findings Include: 1. Review of R42's admission Record documented R42's initial admission date to the facility as 06/17/21. The same document lists diagnoses for R42 including but not limited to unspecified dementia, unspecified severity, simple chronic bronchitis, and protein-calorie malnutrition. R42's Minimum Data Set (MDS) assessment reference dated 4/2/2024 documents a BIMS score of 0, indicating R42 has severe cognitive impairment. R42's Order Summary documents an order dated 5/24/2024 health shake 4 oz. (ounces) with meals. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adaptive utensils for 1 of 1 residents (R32) reviewed for assistive devices in the sample of 46.

Inspectors wroteBased on interview and record review, the facility failed to monitor culture and sensitivity results and prescribe appropriate antibiotic to treat a Urinary Tract Infection (UTI) for 1 of 1 residents (R71) reviewed for UTI's in the sample of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from sexual abuse for 3 of 3 (R2, R9, R11) residents reviewed for abuse in the sample of 34. This failure occurred on [DATE] when V4 (Physician/Co-Medical Director) asked to see and touch R9's genitalia (inappropriate word for female genitalia), while R9 was sitting in the lobby of the facility near the front doors. R9 stated this had been going on for a few months, she would get upset by V4's behavior, her anxiety would rise before he was scheduled to visit, and she began wondering if she had said something to initiate this behavior and began blaming herself. R9 stated she was afraid to tell anyone because it would be her word against his and no one would believe her. The Immediate Jeopardy began on [DATE] when V4 was witnessed by this surveyor making inappropriate sexual comments to R9. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents assessed as being a high risk for elopement were adequately supervised and then failed to identify this same resident as an elopement risk after an elopement for 1 of 3 (R1) residents reviewed for accidents and supervision in the sample of 34. This failure resulted in R1, who had a history of confusion and was assessed as being a high risk for elopement, exiting the facility without staff knowledge, at an unknown time, walking 4.4 miles to a neighboring town along a busy highway where he was located by facility staff at 7:00 AM on 4/13/24. The Immediate Jeopardy began on 4/13/24 when R1 exited the facility without staff knowledge. R1 walked approximately 4.4 miles and was found by facility staff at 7:00 AM on 4/13/24. V1 (Administrator) was notified of the Immediate Jeopardy on 4/29/24 at 1:57 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for 3 (R23, R10, R27) of 13 residents reviewed for medication errors in the sample of 34. This resulted in R23 experiencing a blood glucose level of 37, altered mental status and being transported by EMS (Emergency Medical Services) to the Emergency Department for evaluation and treatment. Additionally, this failure resulted in R27 experiencing anxiety and an increase in behavioral symptoms, requiring an inpatient psychiatric hospitalization. The immediate Jeopardy began on 4/9/24 when insulin was administered to R23 without first performing a blood glucose check as ordered. V53 (Chief Clinical Officer) and V66 (Regional Operations Clinical Consultant) were notified of the Immediate Jeopardy on 5/8/24 at 2:40 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure performance improvement activities were implemented to track medical errors and adverse events, analyze causes and implement preventative actions/mechanisms for Quality Assurance (QA) and resident care. This failure has the potential to affect all 89 residents residing in the facility. Findings Include: Facility Medication Error reports dated 11/3/23 through 5/3/24 documented that R29 and R25 were the only residents noted to have medication errors in the facility during this time. On 5/10/24 at 11:30 AM, V66 (Regional Operations Clinical Consultant) acknowledged that the facility should have identified medication errors that also occurred on 4/9/24 involving R23 and R10, in which insulin was administered without first completing blood glucose testing as ordered. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure medications were available and administered as ordered for 3 (R23, R24, and R28) of 13 residents reviewed for medication administration in the sample of 34. Findings Include: 1. R28's admission Record documented R28 was [AGE] years old with an admission date to the facility of 05/05/2023. Diagnoses listed in their entirety on this document are: Hemiplegia, Unspecified Dementia, essential hypertension, Paroxysmal atrial fibrillation, peripheral vascular disease, atherosclerotic heart disease, hyperlipidemia, low back pain, gastro-esophageal reflux disease, neuromuscular dysfunction of bladder, fatty liver, unspecified psychosis, depression, bipolar disorder, and personal history of transient ischemic attack. Review of R28's Order Review Report documented the following active orders: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with psychiatric diagnoses, who were at risk of elopement, were accurately assessed and appropriately supervised for 1 of 3 (R2) residents reviewed for accidents and supervision in the sample of 17. This failure resulted in R2, who has a diagnosis of schizoaffective disorder and a history of suicidal ideation's exiting the facility without staff knowledge on [DATE] sometime between 4:45 AM and 5:30 AM. R2 was located slightly more than two tenths of a mile from the facility at approximately 6:30 AM, sitting outside an abandoned building on top of a truck camper shell, in the rain. R2 had to cross a busy highway to get to this location. This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when R2 exited the facility with out staff knowledge. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff were trained and the facility had the necessary equipment to meet the needs of a resident with a tracheostomy for 1 of 1 resident (R3) reviewed for tracheostomy care in the sample of 17. This failure resulted in R3 becoming short of breath shortly after admission with the facility unable to locate the necessary equipment to provide oxygen to R3 via the tracheostomy, causing R3 to be anxious and scared and then being transferred to the local hospital for oxygenation. Findings Include: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure sufficient staff was in place to meet the needs of the residents. This failure has the potential to affect all 93 residents currently residing at the facility. Findings Include: The facility Resident Listing Report dated 3/14/24 documents 93 residents currently reside at the facility. On 3/21/24 at 9:37 AM, V39 (CNA/Certified Nursing Assistant) stated he works on day shift and when he comes to work after night shift has been working with less staff, the residents tell him it took night shift a long time to answer their call lights. V39 stated he came to work on 3/16/24 at 4:00 PM and there were five CNA's working. V39 stated five CNA's are not enough to meet the needs of the residents because there are so many residents with behaviors. When asked what type of behaviors. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to respond in a timely manner to resident's requests and/or needs for assistance to promote dignity for 4 of 9 (R4, R8, R11, R12) residents reviewed for dignity in the sample of 17. This failure would result in a reasonable person experiencing feelings of embarrassment, shame, anger, and frustration. Findings Include: 1. R8's admission Record with a print date of 3/25/24 documents R8 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, osteoarthritis, heart failure, hypertension, and bradycardia. R8's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 01, which indicates a severe cognitive impairment. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure activities of daily living were provided per current standards of practice for 7 of 9 (R1, R3, R4, R5, R8, R11, and R12) residents reviewed for activities of daily living in the sample of 17. Findings Include: 1. R1's admission Record with a print date of 3/21/24 documents R1 was admitted to the facility on [DATE] with diagnoses that include sepsis, pulmonary disease, chronic kidney disease, atrial fibrillation, left hip osteoarthritis, and left artificial hip joint. R1's MDS (Minimum Data Set) dated 2/12/2024 documents a BIMS (Brief Interview for Mental Status) score of 12, which indicates R1 has a moderate cognitive impairment. This same assessment documents R1 is dependent on staff for bathing. R1's current Care Plan documents a Focus Area initiated on 9/28/23 of Self-Care deficits as Evidenced by: [...]

Inspectors wroteBased on interview and record review the facility failed to implement their Abuse policy when they failed to ensure an allegation of narcotics diversion was reported timely to the Administrator for 1 of 3 (R7) residents reviewed for abuse in the sample of 17. Findings Include: R7's admission Record with a print date of 3/25/24 documents R7 was admitted to the facility on [DATE] with diagnoses that include pain due to internal orthopedic prosthetic devices, rotator cuff tear or rupture of left shoulder, paraplegia, colostomy, and stage 4 pressure ulcers. R7's MDS (Minimum Data Set) dated 3/12/24 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R7 is cognitively intact. R7's current Care Plan initiated 3/21/24 documents a Focus Area of Pain/Opioid Therapy r/t (related to) chronic pain. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of narcotics diversion was reported to the Administrator timely for 1 of 3 (R7) residents reviewed for abuse in the sample of 17. Findings Include: R7's admission Record with a print date of 3/25/24 documents R7 was admitted to the facility on [DATE] with diagnoses that include pain due to internal orthopedic prosthetic devices, rotator cuff tear or rupture of left shoulder, paraplegia, colostomy, and stage 4 pressure ulcers. R7's MDS (Minimum Data Set) dated 3/12/24 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R7 is cognitively intact. R7's current Care Plan initiated 3/21/24 documents a Focus Area of Pain/Opioid Therapy r/t (related to) chronic pain. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure pain and the effectiveness of pain medication was evaluated for 1 of 3 (R1) residents reviewed for pain in the sample of 17. Findings Include: R1's admission Record with a print date of 3/21/24 documents R1 was admitted to the facility on [DATE] with diagnoses that include sepsis, chronic kidney disease, atrial fibrillation, depression, anemia, left artificial hip joint, gout, and osteoarthritis of left hip. R1's MDS (Minimum Data Set) dated 2/12/2024 documents a BIMS (Brief Interview for Mental Status) score of 12, which indicates R1 has a moderate cognitive impairment. R1's current Care Plan documents a Focus Area initiated on 11/24/23 of The resident is on pain medication therapy r/t (related to) chronic pain. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy services were provided per current standards of practice for 2 of 3 (R1 and R7) residents reviewed for pharmacy services in the sample of 17. Findings Include: 1. R1's admission Record with a print date of 3/21/24 documents R1 was admitted to the facility on [DATE] with diagnoses that include sepsis, chronic kidney disease, atrial fibrillation, depression, anemia, left artificial hip joint, gout, and osteoarthritis of left hip. R1's MDS (Minimum Data Set) dated 2/12/2024 documents a BIMS (Brief Interview for Mental Status) score of 12, which indicates R1 has a moderate cognitive impairment. R1's current Care Plan documents a Focus Area initiated on 11/24/23 of The resident is on pain medication therapy r/t (related to) chronic pain. [...]

Inspectors wroteBased on interview and record review, the facility failed to safely transport a resident in a wheelchair to prevent an accident for 1 of 3 residents (R3) reviewed for accidents in the sample of 3. This failure resulted in R3 sustaining a fall from R3's wheelchair that resulted in a laceration to the bridge of the nose, requiring treatment of glue to the nose at the local hospital emergency room. This past non-compliance occurred between 9/16/23 and 9/22/23.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that equipment and counterops were effectively cleaned and sanitized to prevent contamination. This had the potential to effect all 85 residents in the facility. The Findings Include: During the initial tour on 3/21/23 at 9:00 AM, upon entering the kitchen gnats were observed flying around the area near the entrance by the dish machine. At this same time, it was observed that water soaked old food debris was pushed up on the clean side of the dish machine next to the clean racks of dishes. This food debris was still observed to be in the same spot on the counter at 11:30 AM when entering the kitchen to observe the serving of lunch. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest managment program. This has the potential to effect all 85 residents residing in the facility. The Findings Include: During the initial walk through in the kitchen on 3/21/23 at 9:00 AM, several gnats were observed flying in the area around the dish machine, hand wash sink and juice dispenser. At this same time during the tour of the kitchen, dried juice was splattered on the juice machine and in/on the grate that catches overflow. Also observed was wet, old food pushed up on the clean side of the dish machine counter. The dried juice splatter on the juice dispensing machine and grate was brought to the attention of V4 (Dietary Manager), who stated that it would be cleaned immediately. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to respond in a timely manner to call lights and residents' requests for assistance for 6 of 6 residents (R37, R40, R42, R38, R186, R132) reviewed for Resident Rights in the sample of 31.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare and serve food at a palatable temperature for 7 of 7 (R9, R28, R38, R32, R42, R186, and R40) reviewed for palatable food in a sample of 33. The Findings Include: On 3/21/23 at 10:00 AM, R32, who was alert and oriented to person, place and time, stated that the food is always cold regardless of the time of the meal. On 03/21/23 at 10:36 AM, R42 was dressed and sitting in her wheelchair, having just returned from dialysis. R42 was alert and oriented to person, place and time, and stated the only complaint she had was that her food is usually cold when she eats what is on the menu. R42 stated the kitchen started serving hall trays first, but the food will still be cold. On 03/21/23 at 12:39 PM, R38 was alert and oriented to person, place and time. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to provide fresh water, or preference of ice water for 5 of 5 residents (R37, R40, R60, R32 and R186) reviewed for fluid preferences in the sample of 31.

Inspectors wroteBased on observation, interview and record review the facility failed to serve dietary supplements as ordered for 2 of 2 (R80 and R186) residents reviewed for supplements in the sample of 33. The Findings Include: 1. R186's admission record documents a date of birth of as 2/23/32 with an admission date of 3/10/23. R186's current physician order sheet does not document a diet order but diet tray cards document that at breakfast super cereal is to be provided and power pudding at lunch and dinner. On 3/22/23 V5 (Cook) confirmed that is what the kitchen has as her diet order. On 3/21/23 at 12:46 PM, R186 stated that she did not get her power pudding on her lunch tray like her tray card states and none is observed on her tray upon delivery to her room. On 3/22/23 at 8:30 AM, R186 tray card documented that she should receive super cereal at breakfast. [...]