Based on observation, interview and record review, conducted during a site visit on 01/24/24, it was determined the facility failed to provide three nutritious, palatable meals. Findings include, but are not limited to:

During a site visit on 01/24/24, the temperature was taken of the last meal delivered to a resident room for the noon meal which was 117 degrees.

During separate interviews, Resident 3, Resident 4, and Resident 5 all stated they preferred to eat in their rooms and food was not hot or palatable when it arrived to their rooms.

Resident council notes for  03/02/23 and meal chat notes for January 2023 were reviewed which both noted residents reporting cold food.

The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 01/24/24.

The facility failed to provide three palatable meals.

Verbal plan of correction: Facility will re-implement use of warming cart for all room trays by tomorrow 01/25/24.

Based on interview and record review, conducted during a site visit on 01/24/24, it was determined the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident. (#1). Findings include, but are not limited to:

Resident 1 no longer resides in the facility.

During an interview on 01/24/24, Staff 1 (Administrator) stated the facility had someone come in to do an audit for survey preparation and discovered an issue with Resident 1's Lorazepam (a narcotic psychoactive medication). The facility reported to APS immediately and began their own investigation. They found his/her narcotic order was changed multiple times and cards/narcotic log did not match the MAR. The facility thought initially that there were many days where resident was given the incorrect dose, but upon further investigation determined the error only occurred on three days. The results of the investigation were provided to APS.

Staff 1 provided the investigation including resident records which revealed Resident 1 was given the incorrect dose of lorazepam as follows:

*08/01/23 was given full tab instead of half tab in the AM;

*08/04/23 was given full tab instead of half tab in the PM; and

*08/05/23 was given full tab instead of a a half tab in the PM.

The findings were reviewed with and acknowledged by Staff 1 on 01/24/24.

The facility failed to carry out medication orders as prescribed.

Verbal plan of correction:  The facility has changed processes for new medications orders or medication order changes. Now if  an order was changed, they discontinue the order in their electronic medication administrator record, return the card and get a new card with the order and dosage to match. This was a facility self-report and they made changes as soon as they caught this error.