Traylor Retirement Community

Inspectors wroteBased on interviews, record review, and review of a facility policy titled Policy & Procedure Manual, Director of Food and Nutrition Services, the facility failed to have a qualified Dietary Manger (DM) who possessed the necessary skills and certifications for a Certified Dietary Manager and who was a clinically qualified nutrition professional, per the facility policy. This failure had the potential to affect all 71 residents receiving meals from the kitchen by compromising the safe preparation, service, and overall management of the facility's dietary program.

Inspectors wroteBased on observations, interviews, and review of facility policies titled Cleaning Instructions: Ice Machine and Equipment, Bare Hand Contact with Food and Use of Plastic Gloves, WET NESTING POLICY, Refrigerator & (and) Freezer Temperature Monitoring Policy, the facility failed to ensure:1) the ice machine was free of a pink substance in the lid;2) staff washed their hands after touching a trash can lid before returning to the tray line;3) spoons, forks, and knives were not wet nesting; and4) the temperatures of the refrigerator/freezer PM temperatures were documented on the temperature logs. These deficient practices had the potential to affect 71 of 71 residents who received meals from the kitchen.

Inspectors wroteBased on observations, interviews, and review of a facility policy titled Equipment Malfunctions and Repairs, the facility failed to maintain essential equipment in safe and effective operating condition. Specifically, water was leaking from a pipe underneath the three-compartment sink and dripping into a pan placed under the sink and one of the facility's two commercial washing machines was non-functional. This was observed by the surveyor on 12/04/2025. The Laundry Supervisor (LS) said the machine had been non-functional for three weeks. The Administrator (ADM) stated the repair company had been to the facility on [DATE], and a part was ordered for the repair on 11/26/2025. Review of e-mails with the repair company revealed the machine had been non-functional since at least 11/17/2025. [...]

Inspectors wroteBased on interview, record review, and review of facility policies titled admission Orders and admission of a Resident, the facility failed to ensure Resident Identifier (RI) #11's physician orders included details necessary for the care and treatment of an indwelling urinary catheter upon admission on [DATE] for an existing urinary catheter. The facility obtained an order on 11/04/2025 for use of a urinary catheter and included the size of catheter RI #11 was to have, but still failed to include details such as care, treatment, changing of the urinary catheter, and any other details the physician may have wished to include, placing the resident at risk for inadequate clinical oversight and unmet care needs. This affected RI #11, one of two residents for whom closed records were reviewed.

Inspectors wroteBased on observation, interview and a facility policy titled Safe and Homelike Environment the facility failed to maintain the exterior physical environment in safe and good repair. Specifically, on 12/3/2025 and 12/4/2025 a damaged soffit with exposed wood and hanging metal was observed on the back side of the building facing a patio area. This concern was brought up during the resident council meeting that took place on 12/03/2025, and staff indicated it had remained in that state for more than a year. Additionally, a discarded water heater was observed near the outdoor patio area where residents may gather. The deficient practices had the potential to affect all 73 residents residing in the facility. Findings Include: An undated facility policy titled Safe and Homelike Environment documented: Policy: [...]

Inspectors wroteBased on observations, interview, review of the facility's policies titled, Food Storage, Cleaning Instructions: Food Preparation Appliances, and a facility document titled, Food Storage Guidelines, the facility failed to ensure: 1. a full size, two inch, baking pan of macaroni and cheese was discarded on the used by date, and 2. a dirty toaster was not stored in the Dry Goods Storage Room. These deficient practices were observed on 9/24/19, during the initial observation of the kitchen. This had the potential to affect all 106 residents in the facility. Findings Include: 1. A review of an undated facility policy titled, Food Storage, revealed: . Procedure: . 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. 14. Refrigerated Food Storage: [...]

Inspectors wroteBased on observations, interview, and review of the facility's policies titled, Food-Related Garbage and Refuse Disposal and Waste Grease Disposable the facility failed to ensure: 1. the double lids on the top of the dumpster were closed and secured on 09/24/19 and 2. the lid on the oil/grease disposal container was closed and secured on 09/24/19. These deficient practices had the potential to affect all 106 residents in the facility. Findings Include: 1. A review of a facility policy titled, Food-Related Garbage and Refuse Disposal, with a revised date of October 2017, revealed: Policy Statement Food-related garbage and refuse are disposed of in accordance with current state laws. Policy Interpretation and Implementation . 2. All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. . 5. [...]

Inspectors wroteBased on observation, interview, record review, and a review of the facility's policies titled, Resource: Final Cooking, Holding and Reheating Temperatures, Kitchen Cloths and Food Storage, the facility failed to ensure: 1)chicken noodle soup was reheated to a temperature of 165 degrees Fahrenheit (F); 2) Wiping cloths were placed in a sanitizing solution when not in use; and 3) food items stored in the walk-in freezer were frozen solid. This had the potential to affect all resident' receiving meals from the kitchen.

Inspectors wroteBased on observation, interview and review of facility's policies titled, MEDICATION STORAGE IN THE FACILITY and SPECIFIC MEDICATION ADMINISTRATION PROCEDURES', the facility failed to ensure an expired vial of flu vaccine was not stored in a medication room refrigerator. This affected one of three medication rooms in the facility.

Inspectors wroteBased on observations, interviews, medical record reviews, review of facility's policies titled, HANDWASHING, Fingerstick Blood Sugar Testing and Glucometer Disinfection, Personal Protective Equipment - Using Gloves, Nebulizer Therapy, SPECIFIC MEDICATION ADMINISTRATION PROCEDURES, INCONTINENT CARE and review of [NAME] AND PERRY'S FUNDAMENTALS OF NURSING, the facility failed to ensure: 1) a licensed nurse washed her hands prior to preparing Resident Identifier (RI) #69's medication and wore gloves during RI #69's nebulizer therapy; 2) a licensed nurse washed her hands before leaving RI #6's room after obtaining RI #6's fingerstick blood sugar (FSBS); [...]