Complete Care At Multi Medical Center LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on surveyor observations, medical record review and facility staff interviews, it was determined that the facility failed to ensure residents had access to a call device system. This was evident for 2 of 2 resident room observations and 1 of 1 shower room observations. The findings include: 1. On 02/24/2026 at 10:34 AM, 02/26/2026 at 6:50 AM and at 8:14 AM Resident #17's call bell device was observed out of the resident's reach (entangled on the headboard).02/26/2026 8:14 AM Interview with RN#13 was conducted while in Resident #17's room. RN #17 nurse located the resident's call bell device entangled behind the resident's headboard. RN #13 untangled the call bell device from being wrapped around the headboard and placed it near the resident's left hand.A review of the resident's medical record revealed that Resident # 17 is totally dependent for all care and bed mobility with contractures to his/her right upper extremity and right sided paralysis. 2.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, observations, food temperature testing it was determined that the facility staff failed to ensure meals were palatable and that cold liquids were served at the correct temperatures. This failure had the potential to affect all residents receiving meals from the facility's kitchen. The findings include: During a tour of the four units on the first and second floors on 10.28.24 between 0900 AM and 10:30 AM the surveyor conducted interviews of over twenty residents. Four residents, 3, #5, #16, and #22, on the 1st floor and two residents, #220, #235 on the second-floor unit, reported that their meals are consistently served cold. All six residents stated they received cold scrambled eggs that morning. Resident # 235 stated that he/she had discussed food concerns with the dietary staff previously. The surveyor met with staff #5 on 11.06.24 at 12: 35 PM. Staff #5, the certified dietary manager (CDM) was asked how often do the dietary staff perform test trays? Staff #5 stated the test tray testing is performed weekly. Additionally, staff #5, CDM stated that meal carts…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews it was determined that the facility staff failed to provide a dignified existence to a resident dependent on ADL care. The deficient practice was evidenced in 1 (#202) of 3 dependent residents assessed for ADL care during the survey. The findings include: On 10/29/24 at 12:43 pm during observation rounds the surveyor observed Resident #202 in their room in bed with a copious amount of mucous overflowing around the tracheostomy dressing and on the right side their neck. Licensed Practical Nurse (LPN) #22 entered Resident #202 room and the surveyor asked the nurse if they would suction the resident due to the copious secretions. LPN #22 verbalized the Respiratory Therapist suctions the resident. Before the surveyor left the resident's room, Resident #202 was still soiled with mucous on their dressing and around their neck. On 10/30/24 at 12:28 pm the surveyor observed Resident #202 in bed and heavily soiled with mucous around the tracheostomy dressing and on the right side of their neck. 11/07/24 03:03 pm during an interview with Director of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interviews it was determined that the residents who participated in the resident council meeting were unaware meetings could be held without the facility staff being present. This deficient practice was discovered during the survey and impacts residents attending resident council meetings. The findings include: On 11/06/24 at 2:09 am during the resident council meeting initiated by the surveyor, fourteen residents attended the meeting. The surveyor asked questions relating to the resident council process. When the surveyor asked the resident attendees if they are allowed to have meetings without the facility staff being present, there was a consensus of the residents who verbalized they did not know they could hold resident council meetings without the staff. The Resident Council President, Resident #55 attended the meeting via iPad video. When Resident #55 was asked if they had any meetings without the staff being present, Resident #55 replied, no. The surveyor asked were they made aware they can hold meetings without the staff being present, Resident #55…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews it was determined that the residents were not notified who the facility Ombudsman was or how to contact them. This deficient practice was discovered during the survey. The findings include: On 11/06/24 at 2:30 pm during the resident council meeting initiated by the surveyor, fourteen residents attended the meeting. The surveyor asked the residents if they knew the name of the Ombudsman and how to contact them. The residents verbalized not knowing the Ombudsman's name or contact information. On 11/06/24 at 3:05 pm during an interview with Guest Services Director #24, when asked if the residents know the Ombudsman and how to contact them. Guest Services Director #24, stated the resident don't know who he/she is. The meeting dates and times for resident council are posted in case the Ombudsman wants to attend the meetings and they will ask the Ombudsman to attend a meeting.

Based on medical record review and staff interview, it was determined the facility staff failed to ensure that a Minimum Data Set (MDS) assessment was accurately coded. This was evident for 1 (Resident #58) of 6 residents reviewed during the survey. The findings include: The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Review of Resident # 58's record on 11/7/24 at 2pm revealed that on 10/1/23 during an annual assessment the facility staff coded the resident MDS Section P 0100 (Physical Restraints) (E) trunk restraint used in a chair or out of bed. A trunk restraint is a physical intervention that limits trunk movement. During an observation of Resident #58 on 11/7/24 at 2:30 pm no trunk restraint was noted and the resident denied using one. During an interview with the MDS Coordinator (staff # 25) on 11/7/24 at 3:00 PM, she stated the MDS was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review, and interviews it was determined that the facility staff failed to meet professional standards by documenting that a medication was administered when it was not observed as administered. This was found to be evident for 1 (#106) out of 7 residents reviewed during the survey. The findings include: Review of Resident #106's physician's orders on 11/5/24 at 9:35 AM revealed an order for Keppra, 20 ml (milliliters) via g-tube two times a day for seizures (9am and 5pm) and Metoprolol Tartrate 12.5mg by mouth two times a day for Tachycardia (9am and 9pm). Review of Resident #106's Medication Administration Record (MAR) on 11/5/24 at 10:35 AM revealed LPN (Licensed Practical Nurse) staff (#28) signed off that the Keppra was not administered on 5/31/23 at 5pm due to the g-tube being clogged; however, on 5/31/23 at 9pm the LPN signed off on the MAR that the Metoprolol was administered. Continued review of the medical record revealed the resident was transferred to the hospital on 6/1/23 to have the g-tube replaced. During an interview with the DON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews it was determined that the facility staff failed to provide showers to a resident who was dependent for ADL care. This deficient practice was evident in 1 (#98) of 1 resident who verbalized not receiving a shower. The findings include: On 10/29/24 at 1:50 pm while speaking with Resident #98, they verbalized not receiving a shower since being admitted to the facility. Resident#98 verbalized not being able to stand independently and they require assistance with a shower. On 11/07/24 at 1:34 pm a review of the Task section in PointClickCare (PCC) revealed there was no documentation to verify the resident had received a shower. The surveyor reviewed Resident #98's care plans and notes to check to see if a shower was offered and the resident refused; there was no documentation to verify the resident refused a shower nor was there a care plan generated because the resident refused a shower. The surveyor asked Director of Nursing (DON) #2 where the documentation was to verify the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews, it was determined that facility staff failed to administer blood pressure medication as ordered by the physician. This deficient practice was evident for 1 of 27 (#18) residents reviewed during the survey. The findings include: On 10/31/24 at 9:32 AM, a review of Resident #18's medication administration record revealed an order for Metoprolol Succinate 25mg (milligram) extended release, to be taken every 24 hours. The order included specific parameters to administer one tablet once daily for hypertension but hold the dose if the systolic BP (blood pressure) is less than 110 and heart rate less than 60. Further review the Resident #18's BP readings revealed that Metoprolol was administered outside the ordered parameter on: 09/26/24-BP 107/59 10/04/24-BP 109/65 10/08/24-BP 103/57 10/11/24-BP 102/62 10/14/24-BP 109/57 During an interview with UM (Unit Manager) #16 on 10/31/24 at 9:11 AM, regarding the administration of blood pressure medication, UM #16 explained that geriatric nursing aides are responsible for obtaining residents' BP and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and record review it was determined that the facility had a medication error rate greater than 5%. This deficient practice was evidenced in 1 (#204) of 5 residents observed during the medication pass during the survey. The findings include: On 11/06/24 at 8:50 am the surveyor observed Licensed Practical Nurse (LPN) #22 prepare medications for Resident #204. The medication cart did not have the resident's antiviral medication that was due at 9:00 am. While LPN #22 gave Resident #204 the medications, he/she refused to take the Fortified Nutritional Shake ordered and the surveyor observed LPN #22 pour the shake into the sink & down the drain. The cup was discarded into the waste basket. On 11/07/24 at 12:29 pm review of the Medication Administration Audit Record revealed that LPN#22 signed of the antiviral medication as being administered on 11/06/24 at 11:43 am which was 1 hour and 43 minutes past the due administration time. Also, LPN#22 signed off the Fortified Nutritional Shake as given on 11/06/24 at 9:00 am, but Resident #204 refused to drink the shake and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, it was determined that facility staff failed to discard expired medications. This deficient practice was evident in 1 out of 4 medication storage rooms assessed during the survey. The findings include: On 11/06/24 at 8:35 AM, during an observation of the medication storage room on Evergreen unit, the surveyor found the following expired medications and medical supply: 3 intravenous bags of 10% Dextrose expired October 2024 Infuvite Adult Multiple vitamin vial expired December 2023 Biopatch Protective Disk expired March 2024 Thick & Easy Clear Drink expired August 2024 On 11/06/24 at 8:54 AM, the surveyor informed the Nurse Unit Manager #16 about the findings. The Nurse Unit Manager #16 explained that both central supply personnel and Evergreen unit clerk are responsible for organizing and managing the medication supply room. All expired items were discarded by Nurse Unit manager #16. On 11/06/24 at 9:00 AM, during an interview with the Evergreen Unit Clerk #6, she explained that she is responsible for organizing and cleaning the medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews, it was determined that facility staff failed to have a system in place to ensure geriatric nursing assistant (GNA) received dementia training annually. This deficient practice was evident for 4 out of 5 (GNA #18, GNA #41, GNA #42, and GNA #43) GNA files reviewed for training. The findings include: On 11/4/24 at 8:27AM, a review of employee file for GNA #18, GNA #41, GNA #42, and GNA #43 revealed no documentation confirming that annual dementia training had been completed within the last 12 months. During an interview with the Educator #39 on 11/4/24 at 10:08, she stated that annual competencies for GNA are typically conducted in April. These competencies include: lift and transfer competencies, catheter and perineal care, bedpan, urinal commode management, activities of daily living documentation, colostomy care, signs and symptoms of hypoglycemia and hyperglycemia, safe swallowing and feeding techniques, weighing and measuring residents, handling dirty linen, mouth care, fall prevention, prevention of skin breakdown, communicating effectively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and resident interview it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment. This deficient practice has the potential to affect all residents. The findings include: On 8/20/2019 complaint MD00142603 was reviewed and alleged that the window in Resident #4's room had a major leak on July 4th after a period of heavy rainfall. At 8:54 AM on 8/20/2019 Resident #4 was interviewed and stated that during the storm on July 4th water was pouring into the room. Resident #4 also stated that facility employees were outside her window on a ladder making repairs to the window after the incident. It was noted at this time that the drywall between the resident's main door and bathroom door was chipped and cracked near the floor, exposing the drywall. Interview with the Maintenance Director on 8/21/2019 at 10:40 AM revealed that the issue stemmed from heavy rainfall hitting the southern side of the building. The Maintenance Director stated that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of employee health records and staff interview the facility staff failed to thoroughly screen for immunity to common childhood diseases, failed to have 2nd step Tuberculosis (PPD) or offer the seasonal vaccination for protection against Influenza completed to those newly hired employees (Employee #10, #11, #12, #13, and #14,). This is evident for 5 of 6 newly hired employees. It was also determined the facility failed to maintain resident care equipment in a manner to prevent the spread of infection and cross contamination (Resident #14). This was evident for 1 of 2 residents reviewed for hydration The findings include: A. Measles is an infection of the respiratory system caused by a virus. The spread of Measles is through respiration contact with fluids from an infected person's nose and mouth, either directly or through aerosol transmission, and is highly contagious. Mumps is a contagious disease that leads to painful swelling of the salivary glands. A virus causes the mumps. The virus is spread from person-to-person by respiratory droplets (for example, when you…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on surveyor observation it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of flies. This deficient practice has the potential to impact all residents. The findings include: On 8/20/2019 at 8:20 AM shortly after entering the facility, surveyors noted 2 adult flies in the conference room adjacent to the resident rehab area. Shortly after at 8:30 AM during an initial tour of the main kitchen, an adult fruit fly was observed in the dry goods storage room. Additional observations of the dry goods storage room on 8/23/2019 at 8:45 AM revealed an adult fruit fly still present in the dry goods room. An adult fly was observed in the hallway outside the 200 Rooms on 8/21/2019 at 12:39 PM. The facility's pest control logs were reviewed on 8/23/2019 and showed that a pest control company services the facility approximately twice monthly. The Administrator and Director of Nursing were made aware of these findings on 8/23/2019 during the exit conference.

Based on observation, resident and staff interviews it was determined that the facility staff failed to provide a private space to support residents right to privacy while conducting their monthly resident council meeting. The findings include: This surveyor was invited to attend the Resident Council meeting held on 08/22/19 from 1:00 PM to 1:30 PM. The Resident Council President conducted the meeting in the dinning room. During the meeting staff members were observed entering the dinning room without knocking or receiving permission to enter. The Recreation Director had posted a sign on the door and closed the doors indicating that a resident council meeting was in progress and requested privacy. The Resident Council President confirmed that during most meetings it is usual that people walk through the room. In an interview with the Director of Nursing on 08/22/19 at 2 PM was made aware of this concern and would speak to the residents about changing the meeting location to better ensure privacy.

Based on record review, observation and interview, it was determined the facility staff failed to assess the need for 2 full side rails on the bed for Resident (#69) and failed to thoroughly assess and determine if an alarming Self-Release belt was a restraint for Resident (#87). This was evident for 2 of 33 residents selected for review during the survey process. The findings include: 1. The facility staff failed to assess the need for 2 full side rails on the bed for Resident #69. Medical record review for Resident #69 revealed on 1/10/19 and 4/17/19 the physician ordered: Clinitron bed for comfort/wound healing. Clinitron Air Fluidized Therapy beds provide an ideal healing environment for compromised skin by minimizing the forces that cause tissue breakdown: pressure, shear, friction, heat and moisture. The Clinitron bed combines air-fluidized and low air loss therapies to provide the highest level of wound care for patients with complex wound care needs. Surveyor observation of the Resident #69 on 8/20/19 at 10:00 AM, 8/21/19 at 12:00 PM and 8/22/19 at 8:30 AM revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview, it was determined that the facility failed to notify the responsible party in writing of a Resident's (#34) transfer to the hospital. This was evident for 1 of 3 residents sampled for hospitalizations. The findings include: On 8-17-19 Resident #34 required transportation to the hospital after becoming unresponsive. The facility notified Resident#34's responsible party by telephone but did not send notification in writing explaining the reason for the transfer to the hospital. On 8-21-19 at 10:00 AM the facility Administrator and the Assistant Director of Nursing confirmed that no written notification explaining the reason for the transfer had been sent to the responsible party.

Based on medical record review, observation and interview it was determined the facility staff failed to review and revise the care plan for Resident (#69) to reflect accurate and current interventions. This was evident for 1 of 33 residents reviewed for care plans during the survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Once the facility staff completes an in-depth assessment of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of nursing staff competencies and staff interview it was determined that facility staff failed to ensure nursing staff received all necessary training's and competency reviews. This was true for 1 out of the 6 nursing staff reviewed. The findings include: A review of competencies for Geriatric Nursing Assistant (GNA) #4 revealed the GNA has only received abuse, Health Insurance Portability and Accountability Act (HIPAA), and safe transfer training. A GNA needs to be competent in skills that will meet residents' needs such as person centered care, dementia care, skin care, and basic nursing care. The Assistant Director of Nursing was interviewed on 8/23/19 at 11:00 AM. Some additional information was provided to the survey team after the survey but not enough to ensure competency was met.

2. The facility staff failed to obtain/document the blood pressure for Resident #69 when parameters were ordered. Medical record review for Resident #69 revealed on 8/30/18 the physician ordered: Metoprolol 12.5 milligrams 2 times a day for high blood pressure/A fib, hold for systolic blood pressure (top number) less than 110 or heart rate less than 60. Atrial fibrillation (AFib) is a quivering or irregular heartbeat (arrhythmia) that can lead to a very fast heart rate and other heart-related complications. Metoprolol belongs to a class of drugs known as beta blockers. These drugs work by slowing down a resident's heart rate and lowering their blood pressure. Review of the Medication Administration Record revealed the facility staff failed to obtain/document the resident's blood pressure or heart rate as ordered; however, documented the administration of the medication from: 4/1/19-4/30/19, 5/1/19-5/31/19, 6/1/19-6/30/19 and 7/1/19-7/31/19 and 9:00 AM and 9:00 PM. Interview with the Director of Nursing on 8/23/19 at 1:00 PM confirmed the facility staff failed to obtain/document the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to affect all residents. The findings include: On 8/20/2019 at 8:30 AM an initial tour of the facility's main kitchen was conducted. The dry goods storage room was observed with a sticky floor with various crumbs and debris scattered about. An adult fruit fly was observed flying in this room. An open packet of Grape Cocktail mix powder was observed on the metal shelf of the dry goods room. Additional observations of the facility's kitchen on 8/23/2019 at 8:45 AM revealed additional crumbs and debris on the floor of the dry goods room as well as an adult fly in the air. Inspection of the dish washing room revealed that the only hand sink was blocked by a large fan and had no hand soap available. The Food Service Director was made aware of the sanitation issues at this time and stated that the facility sweeps and cleans daily. The Administrator and Director of Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview it was determined that the facility failed to maintain kitchen equipment in safe operating condition. This was evident for 2 pieces of equipment in the main kitchen. The findings include: On 8/20/2019 at 8:30 AM during an initial tour of the facility's kitchen observation of the 3 compartment sink revealed a leak in the drain pipes dripping into a large plastic bin. The Food Service Director stated that maintenance staff knew about the leaks and they were waiting for repairs to be completed. A leak was also found in the dishwashing room under the garbage disposal on the dishwashing line. This leaks was dripping into a large plastic bin and contained wet, dissolved food residue that could be used as a food source by pests. These leaks were still present in the kitchen during additional inspections on 8/23/2019 at 8:45 AM. The Administrator and Director of Nursing were made aware of these findings on 8/23/2019 during the exit conference.