Browning Masonic Community, Inc

Based on observation, staff interview, medical record review, review of drug manufacturer instructions for use, and policy review, the facility failed to ensure medications were provided as ordered. This affected two (#23 and #48) of five residents reviewed for medication administration. The facility census was 62.

Findings include:

1. Review of the medical record for Resident #23 revealed an admission date of 02/17/25 with diagnoses including hypertension, heart disease, and multiple sclerosis.

Review of the activities of daily life (ADL) functional assessment, dated 11/21/25, revealed Resident #23 was oriented to person, place, and time, but may have some occasional forgetfulness.

Review of the medication evaluation for self-administration, dated 02/17/25, revealed Resident #23 relied on staff for medication administration.

Review of the physician order dated 03/08/25 revealed Resident #23 received metoprolol tartrate (a blood pressure medication) 25 milligrams (mg), 1/2 tablet (12.5 mg), by mouth two times daily with instructions to hold for systolic blood pressure (SBP) less than 100 millimeters of mercury (mmHg) or heart rate less than 60 beats per minute (BPM).

Review of the January 2026 medication administration record (MAR) for Resident #23 revealed the blood pressure and pulse were documented alongside the record of medication administration of metoprolol tartrate. Further review of the January 2026 MAR revealed Resident #23 received metoprolol during the morning on 01/03/26 when her hear rate was 59 BPM, on 01/14/26 when her SBP was 97 mmHg, on 01/15/26 when her SBP was 98 mmHg, on 01/16/26 when her SBP was 90 mmHg, on 01/28/26 when her hear rate was 59 BPM, and on 01/31/26 when her heart rate was 58 BPM. Additionally, Resident #23 received metoprolol during the evening on 01/30/26 when her heart rate was 56 BPM.

Interview on 02/05/26 at 11:50 A.M. with the Director of Health Services (DHS) confirmed Resident #23 received metoprolol tartrate outside the physician's prescribed parameters in the morning on 01/03/26, 01/14/26, 01/15/26, 01/16/26, 01/28/26, 01/31/26, and during the evening on 01/30/26.

2. Review of the medical record for Resident #48 revealed an admission date of 06/01/24 with diagnoses including dementia, type II diabetes, and hypertension.

Review of the ADL functional assessment, dated 11/26/25, revealed Resident #48 was oriented to person, place, and time, but may have some occasional forgetfulness.

Review of the physician order dated 11/05/25 revealed Resident #48 was ordered Novolog (aspart) flex 100 units per milliliter (U/ml) subcutaneously per sliding scale four times daily before meals at and bedtime with direction to given four units of insulin for blood glucose levels between 301 and 350 milligrams per deciliter (mg/dL).

Review of the physician order dated 12/20/25 revealed Resident #48 was ordered donepezil (a medication used to treat cognitive function) 23 mg one tablet by mouth once daily at bedtime for memory loss.

Review of the physician order dated 01/20/26 revealed Resident #48 was ordered Novolog (aspart) flex 10 units subcutaneously two times daily (before breakfast and lunch) for type II diabetes mellitus.

Review of nursing medication administration progress notes, dated 01/02/26, 01/06/26, 01/07/26, and 01/10/26, revealed the 23 mg dose of donepezil was not available and a 20 mg dose of donepezil was administered.

Review of a progress note dated 01/11/26 revealed Resident #48's daughter would pick up Resident #48's donepezil from the pharmacy and drop it off 01/12/26.

Observation on 02/04/26 beginning at 7:50 A.M. revealed Licensed Practical Nurse (LPN) #140 obtaining Resident #48's blood glucose level with a glucometer and revealed a reading of 330 mg/dL. Continued observation revealed LPN #140 returned to the medication cart and removed Resident #48's Novolog FlexPen, applied a new, disposable needle, and turning the dial to 14 units. LPN #140 explained Resident #48 received a dose of 10 units and based on the resident's current blood glucose level, would receive an additional four units. Continued observation revealed LPN #140 administering the dose to Resident #48.

Interview on 02/04/26 at 7:55 A.M. with LPN #140 confirmed she did not prime the insulin pen after applying a new disposable needle. LPN #140 believed the pen only had to be primed when it was new.

Interview on 02/05/26 at 1:36 P.M. with the DHS and concurrent review of Resident #48's progress notes, confirmed Resident #48 did not receive the prescribed dose of donepezil on 01/02/26, 01/06/26, 01/07/26, and 01/10/26. The DHS further stated Resident #48's daughter used an outside pharmacy to fill Resident #48's prescriptions.

Review of drug manufacturer instructions for use for a Novolog FlexPen, dated 2009, revealed the syringe (pen) should be prepared by screwing a new needle onto the FlexPen and after the needle was in place and perform an air shot before administering an injection. Further review revealed directions to perform an air shot (priming the needle) included to dial two units on the pen, and hold the syringe with the needle pointing up, and tap reservoir gently to remove air bubbles to top of needle. Press the push button on the syringe as far as it will go until a drop of insulin appears. Further review revealed the prescribed insulin dose should be administered after priming the syringe.

Review of the policy titled, Medication Administration

Based on medical record review, review of the incident log, staff interview, and policy review, the facility failed to thoroughly investigate fall incidents. This affected one (#60) of five residents reviewed for falls. The facility census was 62.

Findings include:

Review of the medical record for Resident #60 revealed an admission date of 03/14/24 with diagnoses including Alzheimer's disease, dementia, and hypertension.

Review of the functional assessment for persons with dementia document, dated 12/11/25, revealed Resident #60 consistently required assistance with transfers or ambulation or requires wheelchair, had poor posture, was unable to translate a thought into purposeful movement, and had continual involuntary movements.

Review of the assisted living facility fall assessment, dated 01/06/26, revealed Resident #60 was at low risk for falls.

Review of the brief cognitive scale rating document, dated 01/28/26, revealed Resident #60 had impaired cognition and required constant assistance in all activities of daily life.

Review of the facility's incident log revealed Resident #60 fell during staff assistance on 01/13/26 at 7:30 P.M.

Review of the nursing progress note, completed by Licensed Practical Nurse (LPN) #167, dated 01/14/26 at 5:30 A.M., revealed Resident #60 was transferring from the wheelchair to bed, indicated she was tired and weak, and started to fall. The nurse aide was able to prevent Resident #60 from falling to the floor by lowering her. The resident denied pain and there was a small area of shearing to her lower back.

Review of the post-fall follow up document, completed by LPN #136 and dated 01/14/26, revealed no post-injury follow up was completed.

Review of the post-fall follow up document, completed by LPN #145 and dated 01/14/26, revealed no post-injury follow up was completed.

Interview on 02/05/26 at 1:09 P.M. with the Director of Health Services (DHS) revealed all residents should be transferred with a gait belt. Continued interview with the DHS and Regional Director of Clinical Services (RDCS) #166, during concurrent review of the facility's investigation into Resident #60 fall on 01/13/26, revealed the facility could provide no evidence the resident assistant present during the fall was interviewed to determine whether a gait belt was in use at the time of the fall, and what Resident #60 may have slid against to cause shearing on her lower back.

Follow-up interview on 02/05/26 at 2:35 P.M. with the DHS and RDCS #166 revealed the DHS directed two nurses to assess Resident #60's skin for shearing on 01/14/26. The DHS and RDCS #166 stated the results of the post-fall follow up, completed by two different nurses on 01/14/26, indicated there were no skin injuries.

Follow-up interview on 02/05/26 at 3:17 P.M. with the DHS revealed she contacted the resident assistant (RA) who was present during the fall and was told by the RA that Resident #60 did not slide against anything and no injury was observed to Resident #60's back. The DHS stated she did not ask the RA whether a gait belt was in use at the time of the fall.

Review of the policy, Fall Management Program

Based on facility document review, observations, and staff interviews, the facility failed to ensure adequate nutritive value for mechanically altered diets. This affected three (#936, #938, and #946) of four residents observed for therapeutic diets. The facility census was 51.

Findings include:

Review of the facility's menu dated 04/01/25 revealed lunch consisted of roast beef sandwiches with Swiss cheese, lettuce, and tomato with French fries.

Observation on 04/01/25 at 11:37 A.M., of Kitchen Supervisor #11 revealed she prepared three mechanical soft roast beef sandwiches for Residents #936, #938, and #946 without including Swiss cheese, lettuce, or tomato. She then retrieved Swiss cheese from the refrigerator and returned to the prep table. Subsequent interview with Kitchen Supervisor #11 confirmed she forgot to include Swiss cheese while preparing the mechanical soft roast beef and was not going to include the cheese.

Observation on 04/01/25 at 12:15 P.M., of lunch service in the memory care unit revealed mechanical soft sandwiches for Residents #936, #938, and #946 were served without Swiss cheese, lettuce, or tomato.

Interview on 04/01/25 at 12:20 P.M., with Certified Nurse Assistant (CNA) #12 confirmed she served mechanical soft sandwiches to Residents #936, #938, and #946 that did not include Swiss cheese, lettuce, or tomato.

Interview on 04/01/25 at 12:20 P.M., with Kitchen Supervisor #11 confirmed she forgot to include Swiss cheese, lettuce, and tomato when she prepared the mechanical soft sandwiches.

Based on observations, staff interviews, and review of policy, the facility failed to safely store food and prepare food in a manner to prevent contamination. This affected all 51 residents receiving food from the kitchen. The facility census was 51.

Findings include:

1. Observation on 04/01/25 at 8:25 A.M., of the walk-in refrigerator revealed a nine pound plastic container of feta cheese with a use by date of 03/13/25, a five pound plastic container of ricotta cheese with a use by date of 01/30/25, and a two gallon zipper bag of shredded meat that was unlabeled and undated. Subsequent interview with Executive Chef #13 confirmed this observation.

Observation on 04/01/25 at 8:35 A.M., of the wall of reach-in coolers located in the prep area of the kitchen revealed a small metal pan of ground meat that was unlabeled and undated, a one-quart round clear plastic container of food labeled CAM, a paper takeout container labeled CAM, a two-quart container of pancetta with a use by date of 03/31/25, a clear plastic bag of goat cheese crumbles with a use by date of 03/27/25, a three-liter square plastic container of tomato paste that was undated and unlabeled, and a 48-ounce round plastic container of chicken salad with a use by date of 03/28/25. Subsequent interview with Executive Chef #13 confirmed this observation.

Observation on 04/01/25 at 8:45 A.M., of the reach-in cooler next to the sink in the serving area of the kitchen revealed one clear plastic pitcher half full of brown liquid without a label, one clear plastic pitcher full of clear liquid without a label, and one small clear plastic container of sliced lemons without a label. Subsequent interview with Dietary Aide #16 confirmed this observation.

Review of policy titled Food and Nutrition Services in Healthcare Facilities, copyrighted in 2023, revealed all containers or storage bags would be legible and accurately labeled and dated.

2. Observation on 04/01/25 at 11:15 A.M., of Kitchen Supervisor #11 preparing mechanical soft sandwiches revealed she donned gloves, touched the food processor, prep table, multiple bowls, a whisk, a measuring cup and a bag of bread. She did not change gloves or perform hand hygiene prior to reaching into the bag of bread and pulling out six slices of bread with contaminated gloves. She continued preparing three sandwiches and placed them in a serving pan with contaminated gloves.

Interview on 04/01/25 at 11:30 A.M., with Kitchen Supervisor #11 confirmed she should have changed gloves and performed hand hygiene prior to touching the bread and sandwiches with her contaminated gloves.

Observation on 04/01/25 at 11:40 A.M., revealed Cook #17 plating food being served to residents. With gloved hands she filled four soup cups, touched utensils and the prep surface of the steam table, went to the deep fryer and pulled a basket of French fries from the oil, touched buttons on the deep fryer, returned to the steam table area and opened the plate warmer cabinet then used her contaminated gloves to put shredded cheese and croutons into the four soup cups. The soup cups were placed on the top of the steam table and served to residents.

Interview on 04/01/25 at 11:45 A.M., with Cook #17 confirmed she used contaminated gloves to place shredded cheese and croutons into soup cups that were served to residents.

Observation on 04/01/25 at 12:05 P.M., of Kitchen Supervisor #11 plating lunch in the memory care kitchenette revealed she had gloves on both hands, touched the insulated food cart, multiple food pans, the front of her uniform and the food thermometer from the breast pocket of her uniform. Kitchen Supervisor #11 did not change gloves or perform hand hygiene prior to touching sandwiches with her contaminated gloves. The contaminated sandwiches were served to residents.

Observation on 04/01/25 at 12:10 P.M., of Kitchen Supervisor #11 plating lunch in the memory care kitchenette revealed she had gloves on her hands when she opened the insulated food cart, touched serving tongs, and touched multiple pans. She did not change gloves or perform hand hygiene prior to transferring two sandwiches from the pan to plates with her contaminated gloves. The contaminated sandwiches were served to residents.

Interview on 04/01/25 at 12:12 P.M., with Kitchen Supervisor #11 confirmed she used contaminated gloves to touch sandwiches that were served to residents and she should have changed gloves and performed hand hygiene prior to touching the sandwiches.

Review of the policy titled Food and Nutrition Services in Healthcare Facilities, copyrighted in 2023, revealed food would be prepared free of harmful organisms and substances, and hand washing would occur during food preparation as often as necessary to prevent contamination.

Based on observation and staff interview, the facility failed to ensure trash cans in the kitchen had tight fitting lids. This affected all 51 residents receiving food from the kitchen. The facility census was 51.

Findings include:

Observation on 04/01/25 at 11:15 A.M., by the prep table in the kitchen revealed a 50 gallon trash can without a lid. Subsequent interview with Kitchen Supervisor #11 confirmed this observation.

Observation on 04/01/25 at 11:20 A.M., in the plating area of the kitchen revealed a 30 gallon trash can without a lid.

Interview on 04/01/25 at 12:25 P.M., with Executive Chef #13 confirmed trash cans in the kitchen did not have lids.

Based on observations, staff interviews and review of a facility policy, the facility failed to store food in a safe and sanitary manner. This had the potential to affect all 54 residents residing in the facility who receive meals from the kitchen. Facility census was 54.

Findings include:

Observation were conducted of food storage in the facility kitchen on 05/21/24 between 7:30 A.M. and 8:05 A.M. Observation of the walk-in freezer revealed ice on the floor and ice hanging from the ceiling, and a bag of diced onions frozen and on the floor under a shelving unit. Observation of the floor throughout the kitchen revealed assorted debris and dirt. Observation of the three-door refrigerator revealed a dirty bottom shelf throughout; an approximately one-half full large pan of green and yellow beans in water with no date or label; a four-quart container of salsa that was approximately one-third full dated 04/11; an approximately one-third full medium container of raw, boneless, skinless chicken breasts dated 05/13/24; a four-quart container of potato salad that was approximately one-half full dated 05/13/24; a four-quart container of pancake mix that was approximately one-third full dated 05/11/24; a two-quart container of meatballs dated 05/03; a four-quart container of bread sticks dated 04/27; a three-quart container of pineapple that was approximately three-quarters full dated 04/31; a two-quart container of pickle relish that was approximately one-half full with no date or label; and no internal thermometer was noted in the refrigerator. Observation of the single door refrigerator revealed there was no internal thermometer. Observation of the dishwasher revealed no dishwasher log.

Interview on 50/21/24 at 7:56 A.M. with Cook #104 verified the identified concerns/findings in the facility kitchen. Cook #104 confirmed all 54 residents residing in the facility receive their meals from the kitchen.

Review of an undated facility policy titled Food Storage revealed leftover food is stored in covered containers or wrapped carefully and securely. Each item is labeled and dated before being refrigerated. Leftover food is used within three days or discarded.