Slaton Care Center

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (Kitchen A) reviewed for dietary services. 1. The facility failed to ensure dietary staff (DA C and [NAME] D) ensured food was stored, prepared, and served under sanitary conditions. Multiple food items which included cornbread mix, cooked cornbread, bread pudding, salad ingredients, and grilled cheese sandwiches were repeatedly left uncovered for extended periods while in the kitchen and on the serving line 2. The facility failed to ensure Dietary staff (Cook D) consistently performed required hand hygiene. The cook repeatedly donned and removed gloves without washing hands before or after glove use while preparing multiple food items. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 4 residents (Resident #44) reviewed for respiratory care. The facility failed to ensure Resident #44 had orders for the administration of oxygen. This failure could place residents at risk of not receiving the care and services to maintain their highest level of well-being. Record review of Resident #44's face sheet dated 12/02/25 reflected a [AGE] year-old male who was initially admitted to the facility on [DATE]. Resident #44 had diagnoses which included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 2 medication carts (Medication Cart A, and Medication Cart B), reviewed for medication storage. 1. The facility failed to ensure Medication Cart B did not contain a loose pill. 2. The facility failed to ensure Medication Cart A did not contain a loose pill. These failures could place residents at risk of not receiving prescribed medications as ordered and place the facility at risk of drug diversions. Observation on [DATE] at 3:09 PM, of Medication Cart B with MA A revealed a small, white, round, loose pill (1/2 pill) found in a drawer of the medication cart. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure menus were followed for 1(Resident #28) of 17 residents reviewed for food and nutrition services. The facility failed to follow the week 1 menu for one lunch service served at the facility on Tuesday 12/2/25 for the one and only resident (Resident #28) that was on a puree therapeutic diet. This failure could place residents at risk of poor intake, and/or weight loss.

Inspectors wroteBased 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 3 residents (Resident #20) reviewed for infection control. LVN A failed to wear proper PPE (a gown) when providing wound care for Resident #20 who was on EBP. This failure could place residents at risk for the spread of infection and cross contaminationRecord review of Resident #20's face sheet, dated 12/03/25, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #20 had diagnoses which included: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident bedrooms measured at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms for 1 of 17 semi-private (room shared by two people, typically with a curtain dividing the room and providing some privacy) rooms (room [ROOM NUMBER]) reviewed for useable living space. The facility failed to ensure room [ROOM NUMBER] (a semi-private room) provided 80 square feet per resident. The square footage was 153 instead of 160 square feet. This failure could place residents at risk of crowding in resident rooms and cause difficulty in providing resident care.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional or special dietary needs for 1 of 5 residents (Resident #1). The facility failed to provide Resident #1 with double portions at meals 3 times a day, per physician orders. This failure could place residents at risk for weight loss, altered nutritional status and diminished quality of life. Findings Included: Record review of Resident #1's face sheet, dated 01/28/2025, revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #1 had the following diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1) The facility failed to keep refrigerator, oven handles, freezer handles, and microwave handles clean. 2) The facility failed to keep all foods completely sealed when stored in the pantry and freezer. 3) The facility failed to store bowls upside down. 4) The facility failed to keep the kitchen free of expired food items. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 2 of 3 food forms (regular, mechanical soft) for 1 of 1 meal reviewed for palatability. 1. The facility lunch trays had vegetables that were lukewarm, the gravy for the meat was too salty, and the potatoes were too spicy for the regular texture and mechanical soft texture meals at lunch on 9/10/24. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident has a right to a safe, clean, comfortable and homelike environment for 1 of 37 residents reviewed for physical environment. 1. The facility failed to ensure Resident #12 had a functioning bathroom light switch. 2. The facility failed to ensure Resident #12 had a safe and secure toilet in the shared bathroom. These failures could place residents at risk for injuries and falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 1 treatment carts (Treatment Cart A) reviewed for pharmacy services 1. The facility failed to ensure the treatment carts were free of expired medical supplies. These failures could place all residents at risk of harm or decline in health due to expired medical supplies.

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen. The facility failed to designate a person to serve as the Dietary Manager who met the required qualifications. The facility designated Dietary Manager had not completed any Dietary Managers certification course or had any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1. The facility failed to ensure foods were processed under sanitary conditions. 2. The facility failed to ensure dietary staff maintained quaternary sanitizer levels within acceptable ranges and sanitizing solutions were tested according to manufacturer guidelines. 3. The facility failed to ensure food and non-food contact surfaces were cleaned. 4. The facility failed to ensure food was protected from possible contamination. 5. The facility failed to ensure staff used good hygienic practices. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 3 of 16 residents (Residents #8, #26, and #29) reviewed for advanced directives, in that: Residents #8, #26 and #28 was listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. These failures could place residents at risk for not having their end of life wishes honored.

Inspectors wroteBased on observation, interview and record, review the facility, failed to ensure sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in the central bath and 9 of 18 resident rooms (40, 42, 44, 46, 51, 52, 54, 56 and 62) reviewed for environment, The facility failed to ensure resident use common areas and rooms were clean and did not need repair, These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident's environment remained as free of accident hazards as is possible; and that each resident received adequate supervision to prevent accidents for 1 of 1 resident (Resident #33) reviewed for supervision, 1)The facility failed to provide effective monitoring and interventions to reduce Resident #33's wandering which was intrusive to other residents' privacy and unsafe for Resident #33 and other residents, 2)The facility failed to maintain the facility as free of accident hazards as possible, in that; oxygen was not stored in a safe manner, chemicals were not stored in a manner to prevent contamination of resident use items, hot water temperatures were not maintained in a safe range, and hazardous areas were not secured. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure menus were followed for 3 of 3 food forms (regular, mechanical soft and pureed) for 3 residents (Residents #20, #23 and #27) reviewed for during mealtime. The facility failed to ensure Resident's #20, #23 and #27 received their meals according to the menu. This failure could place residents at risk for unwanted weight loss and hunger.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 2 of 2 meals observe for 2 3 of 2 residents with orders for puréed diet (Residents #20 and 23 and 27 ) reviewed for nutrition services and one resident on a mechanical soft diet (Resident #27); in that: The facility failed to provide food that was in a form to meet resident needs for 2 of 2 meals observed (8/01/23 and 8/02/23 - Lunch) for 2 of 2 residents with the orders for puréed diets (Residents #20 and 23) and one resident on a mechanical soft diet (Resident #27). Foods were not in a pureed form and mechanical soft foods were not in the form called for on the menu. This failure could place residents at risk of decreased food intake and choking.

Inspectors wroteBased on observation, interview and record review, the facility failed to 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 16 residents (Residents #32) and 1 of 1 staff (CMA A) reviewed for infection control. 1. CMA A failed to properly clean multi-use equipment between each resident. 2. CNA A failed to perform hand hygiene between glove changes when providing wound care for Resident #32. These failures could place residents at risk for spread of infection and cross contamination during incontinent care and medication administration.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident bedrooms measured at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms for 1 of 61 semiprivate rooms (room [ROOM NUMBER]) reviewed for useable living space. The facility failed to ensure Room # 7 (a semi-private room) provided 80 square feet per resident. The square footage was 153 instead of 160 square feet. This failure could place residents at risk of crowding in resident rooms and cause difficulty in providing resident care.