Auburn Ravine Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one Certified Nursing Assistant (CNA), CNA 2, of five sampled CNAs had a valid CNA license. This failure had the potential to result in all 55 residents in the facility to receive care from an unqualified person. Findings: During a concurrent interview and record review on [DATE] at 11:44 a.m. with the Director of Nursing (DON), the CNA 2's license verification was reviewed. The DON confirmed CNA 2's license verification indicated an expiration date on [DATE]. The DON stated she expected CNAs who worked at the facility to have a valid CNA license. During a concurrent observation and interview on [DATE] at 11:48 a.m. with the Director of Staff Development (DSD) in the facility's dining room, CNA 2 was assisting residents with their lunch meal. The DSD stated she was aware CNA 2's license was getting close to expiration, CNA 2 had not yet submitted an updated CNA license and confirmed CNA 2 was currently working a CNA shift. An…

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 interview, and record review the facility failed to maintain an infection control program for a census of 55 residents when: 1. Facility staff were observed not performing hand sanitation when entering and exiting resident's rooms; 2. Soiled linens were processed without adequate use of Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses); and, 3. The washing machine's water temperature was not monitored. These failures decreased the facility's potential to prevent the spread of disease and infections among residents. Findings: 1. During an observation and concurrent interview with Environmental Service 1 (EVS 1) on 7/18/24 10:32 a.m., the EVS 1 was observed entering and exiting resident rooms 24, 25, 12, and 13 without performing hand sanitation. The EVS 1 was observed to push her cart near room [ROOM NUMBER], entered room [ROOM NUMBER] with gloved hands without sanitizing her hands. The EVS 1 was observed to exit room…

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 interview and record review the facility failed to develop, implement, and monitor an infection control program with the use of antibiotics when: 1. The Infection Prevention and Control Program (IPCP) failed to monitor the laboratory indications on the use of antibiotics. 2. There were inadequate tracking tools in use for tracking of residents on antibiotics and the indications for the use of antibiotics 3. There were inadequate infection control inservices for the facility staff on handwashing. These failures had the potential for residents to be exposed and acquire infectious diseases causing illness. Findings: 1. During an interview with the Infection Preventionist (IP) on 7/18/24 02:35 PM the IP was asked to provide the tracking tool she used to monitor residents who were using antibiotics. The IP was further asked aside from the tracking tool she used what were the clinical indications for the use of the antibiotics. The IP provided a map of the facility which she stated she used to monitor…

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 interview, observation, and record review, the facility failed to ensure the required in-service trainings for three of four sampled Contracted Certified Nursing Assistants (CCNA 1, CCNA 2, and CCNA3) and three of five sampled facility employed Certified Nursing Assistants (CNA 2, CNA 3, and CNA 4), when the facility was unable to provide documentation to demonstrate the CCNAs and CNAs had no less than 12 hours per year of continuing competencies including dementia (a loss of memory and problem-solving abilities which interfere with daily life) management and abuse prevention. These failures had the potential to result in CCNAs and CNAs not identifying and reporting abuse nor being able to effectively care for residents with dementia. Findings: In an interview on 7/18/24 at 2:59 p.m., the Director of Clinical Operations (DCO) stated the facility used contracted staff through staffing agencies and she expected those staffing agencies to provide CCNAs mandatory training documentation for facility to review before scheduling the CCNAs to perform patient care. During a…

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 observations, interviews and record review, the facility failed to ensure baseline care plans (instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) were developed, implemented, and signed by the resident or responsible party within 48 hours of admission for two out of 15 sampled residents (Residents 260 and 261). This failure had the potential to cause residents and staff to be unaware of the residents' plan of care. Findings: A review of Resident 260's admission record indicated Resident 260 was admitted to the facility on [DATE], with diagnoses including sepsis (a life-threatening complication of an infection) and urine retention (difficulty urinating and completely emptying the bladder). During a concurrent observation and interview on 7/16/24 at 9:07 a.m., with Resident 260 in the resident's room, Resident 260 was observed with a urinary catheter. Resident 260 stated, I was transferred here from the hospital about three…

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, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for four residents (Residents 1, 18, 28, and 29) of 15 sampled residents when: 1. Resident 1 was administered morphine ER (extended release, narcotic pain medication) 15 mg (milligram, a unit of measurement) and pramipexole (medication used to treat restless leg syndrome) 0.125 mg at 11:13 a.m. when it was scheduled at 8 a.m.; 2. Resident 18 was administered omeprazole (used to treat heartburn) 20 mg and gemfibrozil (medication to help lower high cholesterol and triglyceride levels in the blood) 600 mg at 8:16 a.m. instead of 30 minutes prior to the breakfast meal.; 3. Resident 28 was administered gabapentin (used to treat nerve pain) 300 mg at 10:17 a.m. when it was scheduled at 8 a.m., and a lidocaine patch 5% (pain relieving patch) at 10:17 a.m. when it was scheduled at 7 a.m.; and, 4. Resident 29 was administered cephalexin (an antibiotic) 250 mg and lisinopril (used to treat high blood pressure and heart failure) 5 mg at 10:56 a.m. when it was scheduled…

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 observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diets (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) during the lunch meal on 7/17/2024 when: 1. 44 out of 44 residents with regular portion size received two scoops (eight ounces (oz.) instead of three scoops (12 oz.) of pasta entrée, 2. Five residents (Resident 6, 9, 14, 33, and 49) with pureed texture diets (diet with modified food texture that is smooth and lump-free for people with swallowing and/or chewing difficulties) received pureed garlic bread sticks instead of soaked white dinner rolls, 3. 16 residents (Resident 7, 11, 19, 21, 25, 29, 32, 38, 39, 40, 43, 46, 52, 56, 110, and 261) who were on Level 5 Minced and Moist texture diets (modified texture diet for people with swallowing and/or chewing difficulties), Heart Healthy/Cardiac diets (diet…

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.

The facility failed to ensure the appropriate food texture for five residents (Resident 6, 9, 14, 33, and 49) who were on a puree texture diet and received pureed ziti with cheese with chunks of pasta and tomato. The total census was 55. This deficient practice had the potential to increase risk to the residents with swallowing and/or chewing difficulties to choke and/or aspirate (a condition in which food, liquids, saliva, or vomit is breathed into the airway). Findings: A concurrent observation and interview on 7/17/24, at 10:27 a.m. with [NAME] (C)1 were conducted during puree preparation for the lunch meal. C1 stated the texture for the puree pasta (ziti with cheese) should be smooth, like mashed potatoes. A concurrent observation and interview on 7/17/24, at 12:38 p.m., with the Dietary Supervisor (DS), were conducted during food sampling of the puree pasta for the test meal tray. The texture of the puree pasta and cheese entrée had a bulky, lumpy consistency when sampling. After tasting, the DS stated the pureed pasta texture was lumpy with noticeable chunks of pasta 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 interview and record review the facility failed to ensure one resident (Resident 10) out of 15 sampled residents was free from unnecessary psychotropic medications when Resident 10 was prescribed an order for lorazepam (a psychotropic medication that affects the brain associated with mental processes and behavior) as needed (PRN) indefinitely. This failure had the potential to cause medication interactions, confusion, and falls. Findings: A review of Resident 10's admission record indicated Resident 10 was admitted to the facility in February 2024 with diagnoses including dementia without behavioral disturbance or anxiety (a group of thinking and social symptoms that interferes with daily functioning) and recurrent depressive disorders (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Resident 10's Order Summary Report (OSR, physician orders), Resident 10 had a physician order for lorazepam, oral tablet 0.5 mg (milligram, a unit of measurement) every 12 hours PRN for anxiety manifested by…

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, interview, and record review the facility failed to ensure safe food handling and storage for food brought in by family for one resident (Resident 2) out of 15 sampled residents. This failure had the potential for Resident 2 to experience foodborne dangers, such as, nausea, vomiting and diarrhea by consuming moldy food. Findings: A review of Resident 2's admission record indicated Resident 2 was admitted to the facility in February 2024 with diagnoses which included dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During a concurrent observation and interview on 7/16/24 at 9:31 a.m. with Resident 2, in Resident 2's room, a transparent plastic container with a red plastic lid was observed on Resident 2's bedside table. Indistinguishable personal food items with greenish-blue spots and fuzzy growth were observed through the container. Resident 2 stated, I'm not sure what those are, my family brought me that a while ago. During a concurrent observation…

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, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal the need for help) was accessible for one of 15 sampled residents (Resident 11). This failure had the potential to result in unmet resident needs and delayed staff response. Findings: A review of Resident 11's admission record, indicated Resident 11 was admitted to the facility in 2016 with diagnoses that included spastic hemiplegia (uncontrolled muscle movements on one side of the body), contracture (permanent tightening of muscles which causes stiffness and prevents normal movement of a body part), polyarthritis (painful inflammation and stiffness affecting five or more joints at the same time), dementia (a loss of memory and problem-solving abilities which interfere with daily life) and a history of falling. A review of Resident 11's Minimum Data Set (MDS, an assessment tool), dated 5/1/24, indicated Resident 11 had moderate memory problems, impairments to both upper body and lower body, and was dependent on staff for mobility and care related to…

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, interview and record review, the facility failed to ensure: 1. The Dietary Manager (DM) met the state's education qualification requirements, as required per federal regulation, to be the DM to carry out the functions of the food and nutrition services; and, 2. The Registered Dietitian (RD) provided frequently scheduled consultation to the DM to include overseeing food safety and sanitation, food preparation, meal service and food storage. These failures resulted in lapses in the delivery of food and nutrition services associated with meal distribution, safe food handling, sanitation, and insufficient oversight of food service operations for a census of 29 residents who received meals from the facility kitchen. Findings: During the annual recertification survey from 9/5/23 to 9/8/2023, multiple issues surrounding the delivery of dietetic services were identified: 1. Meal distribution accuracy - The menu/recipes were not followed and the portion size of food items were not served correctly, and 2. Safe food handling and sanitation: a. The ice machines in 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, interview, and record review, the facility failed to ensure one dietary personnel was competent to carry out the functions of the food and nutrition service when the [NAME] 1 (CK 1) was unable to verbalize the process of properly cooling down cooked food and was unable to practice safe food handling while preparing food for a census of 29 residents who received food from the facility kitchen. These failures had the potential to cause food borne illness in a potentially compromised population. Findings: During an interview with the CK 1 on 9/6/23, at 9 a.m., the CK 1 explained the cooling down process of the cooked food. The CK 1 stated he would put the cooked meat in the refrigerator to cool down in order to slice the meat easier. He then stated he would reheat the meat to 150 degrees Fahrenheit (F, a unit to measure temperature). In a concurrent review of the cooling log (a log to verify the effectiveness of the cooling process from 140 degrees F to at least 41 degrees F within the maximum cooling period of six hours), the CK 1 stated he had never seen the log…

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, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person. It could be part of a treatment or medical condition and is normally prescribed by a physician.) during the lunch meal on 9/6/23 when: 1. Six residents (Residents: 4, 6, 11, 23, 27, and 29) with small portion and/or consistent carbohydrate (CCHO, a diet to help keep blood sugar levels stable) received half of a white roll instead of a whole white roll; 2. Nine residents (Residents: 3, 5, 9, 11, 15, 20, 21, 25, and 29) with mechanical soft texture diets (chopped or ground food prescribed to those who have trouble chewing and swallowing) received whole spears of asparagus and sweet potato with the peel instead of diced asparagus and sweet potato without the peel; 3. 14 residents (Residents: 1, 2, 6, 7, 8, 13, 16, 17, 18, 19, 22, 24, 26, and 28) who were not on CCHO and/or small portion diets got two ounces (oz, a unit of measurement) of tapioca pudding instead 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, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service safety when: 1. Food items were found with missing or incorrect labels and dates; 2. Food items found expired and available for use; 3. A food item was found opened and uncovered to prevent cross contamination (the unintentional transfer of bacteria and substances from one food to another); 4. Trays of prepared food were found uncovered, unlabeled and/or undated; 5. Drawers which stored clean ready-to-use utensils were dirty and one was broken; 6. Ice machines in the kitchen and in the nourishment room were not clean; 7. A juice dispenser was not cleaned per the manufacturer's instruction; 8. One Dishwasher did not perform the sanitizer concentration recording appropriately; and, 9. One [NAME] was unable to verbalize the proper cooling down process and did not perform safe food handling practices during food preparation. These failures decreased the facility's potential to prevent food-borne…

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, interview, and record review, the facility failed to provide a clean environment for the residents and visitors when one of one garbage dumpsters, located outside the facility, were not secure with the dumpster lids closed. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During a concurrent observation and interview on 9/6/23 at 9:15 a.m., the facility's outside garbage dumpster lids were open, there were bags of garbage in the dumpster bin and trash was scattered on the ground around the dumpster bin. The Front of House Supervisor (FOHS) stated. [the dumpster] is supposed to be closed at all times to keep pests out of it. During an interview on 9/7/23 at 3:55 p.m., the Dietary Manager (DM) stated he expected the dumpster area to be kept clean and dumpsters should have been closed with tight fitting covers per their policy and to prevent pest and rodent activity. A review of the undated departmental policy and procedure titled, .FOOD SAFETY…

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, interview, and record review, the facility failed to ensure staffing requirements were met when the facility did not employ a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time (40 hours per week) basis. This failure resulted in a lack of administrative oversight and supervision and has the potential to affect the quality of care delivered to all residents by nursing staff. Findings: During a record review on 9/5/23, of the facility's staffing records for the month of August 2023, it was noted the DON was not present in the facility on Thursdays and Fridays. During an interview on 9/6/23 at 3:22 p.m. with DON, DON stated, she works three days a week, Monday, Tuesday and Wednesday, eight hours a day. This has been her schedule for the last two years. DON stated she understood the DON position should be full-time, but she can only work part-time. During an interview on 9/7/23 at 11:00 a.m. with Administrator (ADM), ADM confirmed the DON doesn't work full-time at the facility. ADM stated the DON position should be full-time. During a…

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, interview, and record review, the facility failed to ensure: -Opened multi-dose inhalers and biologicals were dated with an open and discard date to ensure they were not used beyond the discard date; and -Expired medications were not available for resident use. The deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their discard date. Findings: During a concurrent observation and interview on 9/5/23 at 10:13 a.m. with Licensed Nurse 2 (LN 2), an inspection of Medication Cart 1 (Med Cart 1) identified one Brand Name (an inhaler to treat asthma) 200 microgram/25 microgram (mcg, a unit of measurement) inhaler and one Brand Name Inhub (an inhaler to treat asthma) 500 mcg/50 mcg inhaler, both opened and unlabeled with an open date. LN 2 reviewed the manufacturer's specifications on the outside of the Brand Name and Brand Name Inhub inhalers. LN 2 stated the manufacturer's specifications indicated both had shorter expirations after first use and should have been labeled with an open date.…

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 observation, interview, and record review, the facility failed to ensure one resident (Resident 1) of 13 sampled residents was free of a significant medication error when she received insulin glargine (a long-acting insulin, medication to lower blood sugar level) 10 times (doses) past the expiration date. This deficient practice had the potential for ineffective use of the insulin, resulting in uncontrolled high blood sugar for the resident. Findings: During a concurrent observation and interview on [DATE] at 11:03 a.m. with Licensed Nurse 1 (LN 1), an inspection of Medication Cart 2 identified one opened insulin glargine 100 units/milliliter (u/ml, a unit of measurement) vial, expired on [DATE], for Resident 1. LN 1 confirmed the finding and stated it should have been removed from the cart and not available for use. A review of Resident 1's medical record indicated a physicians' order, dated [DATE], for insulin glargine 100 u/ml, give 10 units sub-q (under the skin) once daily at bedtime. During a…

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, interview, and record review, the facility failed to maintain an infection prevention and control program for one of 13 sampled residents (Resident 1) when hand hygiene was not performed during medication administration and an eye drop was not handled with infection control precautions. These failures had the potential to result in transmission of infection in the facility for all 29 residents. Findings: During a medication pass observation on 9/5/23 at 9:16 a.m. with Licensed Nurse 1 (LN 1), the LN 1 was observed preparing to administer medications to Resident 1, including a Brand Name eye lubricant eye drop. The LN 1 put on a pair of gloves, opened a binder that contained medical records and flipped through multiple pages before closing it. With the same gloves, LN 1 picked up Resident 1's medications and entered the resident's room. LN 1 removed the cap from the eye drop bottle and placed it directly on Resident 1's bedside table, next to her breakfast tray. LN 1 then administered two drops into each of Resident 1's eyes, all without changing gloves or…

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, interview, and record review, the facility failed to maintain equipment in safe operating condition and good repair when one reach-in freezer had a torn gasket and ice buildup. This failure had the potential to result in the freezer not holding proper temperatures for frozen foods stored inside. Findings: During an initial kitchen tour on 9/5/23 starting at 8:58 a.m., the reach-in freezer was found to have a torn gasket (a seal around the door that helps keep the cold air in and warm air out) and ice buildup (an accumulation of ice that occurs when warm or humid air flows into a freezer). During a concurrent observation and interview on 9/5/23 at 10:56 a.m., the Front of House Supervisor (FOHS) confirmed the reach-in freezer had a torn gasket and ice buildup. The FOHS added, the torn gasket made the freezer door not shut properly and could negatively affect the frozen food. During an interview on 9/7/23 at 3:55 p.m., the Dietary Manager stated the reach-in freezer gasket needed to be replaced to prevent ice buildup and maintain freezer temperature. A review 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.