River Valley Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a person-center care plan for one of four residents (Resident 26) sampled for care plans, to reflect Resident 26's required need of the assistance of two helpers with Activity of Daily Living (ADL's, which included turning resident in bed, bathing, and changing her brief [incontinent underwear that absorb urine and feces]). This failure had the potential to lead to inaccurate provision of care and adverse health outcomes for Resident 26. Findings: A review of the facility's policy titled Care Plans, Comprehensive reviewed 9/2024, indicated A comprehensive care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 1. The care plan interventions are derived from analysis of the information gathered as part of the comprehensive assessment. The comprehensive care plan will: .b. Describe the services 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not provide Resident 7 with extensive assistance while eating her lunch, as deemed necessary by her care plan (a document that outlines a resident's specific goals and needs). This failure had the potential to foster a decrease in the resident's participation in her activities of daily living (ADLs) to maintain good nutrition. Findings: A review of a facility policy titled, Activities of Daily Living (ADL), Supporting, with a revised date of August 2024, indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) as practicable as possible. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition A review of a facility policy titled, Care Plans, Comprehensive, with a reviewed date of September 2024, indicated, A comprehensive care plan that includes…

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 an evaluation and documentation, of a red area, was completed for one of two residents (Resident 26) sampled for skin conditions, when Resident 26 was identified to have a red area on her bottom on admission but there was no further documentation about the red area for the next three weeks. This failure had the potential for Resident 26's skin condition to become worse and cause significant pain and negative clinical outcomes. Findings: A review of the facility's policy titled Prevention of Pressure Ulcers/Injuries revised September 2024, indicated Monitoring 1. Evaluate, report and document potential changes in the skin. A review of Resident 26's admission record indicated, Resident 26 was readmitted to the facility on [DATE] after a hospital stay, with diagnoses that included respiratory failure with hypoxia (lack of oxygen to the brain), pneumonitis (lung infection) due to inhalation of food and vomit, Dysphagia (difficulty with…

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 safety of one of nine sampled residents (Resident 79) reviewed for accidents and hazards when Resident 79 was found to have nine razors and one pair of tweezers in her room. This failure had the potential for Resident 79 to cause physical and psychosocial harm to herself and to other residents in the secured unit. Findings: During a record review of facility policy titled Safety and Supervision of Residents dated October 2024, indicated employees shall be trained in potential accident hazards, how to identify and report accident hazards, and try to prevent avoidable accidents. Facility policy further indicated that resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. During a record review of Resident 79's admission record, Resident 79 was admitted to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three dietary aides (responsible for dishwashing) was competent on the use of the three-compartment sink (used in food services to properly wash, rinse, and sanitize dishes and utensils) procedure for manual dish washing in the kitchen. This failure placed all residents at risk for cross contamination and acquiring food-borne illnesses. Findings: A review of the facility policy titled Manual Warewashing [dishes and utensils], revised 10/2022, indicated all cookware, dishware, and serviceware that is not processed through the dish machine will be manually washed and sanitized (using chemicals to kill bacteria). The dining service staff will be knowledgeable in proper technique including: - Soap dispensing. - Wash temperature at no less then 110 degrees Fahrenheit. - Chemical sanitizing dispensing. - Chemical sanitizer testing and concentration. Appropriate test strips will be utilized to measure the concentration of the sanitizer…

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 that the Medical Director (MD) supervised the development and implementation of mitigating a scabies outbreak that effected 31 residents. This failure resulted in a six-month scabies outbreak in the facility. Findings: A review of Medical Directorship Agreement, dated 01/01/2019 indicates the MD is involved at all levels of individualized patient care and supervision, and for all persons served by the facility. The MD services as the clinician who oversees and guides the care that is provided'. The MD is responsible for coordinating of medical care in the facility to ensure that adequate and appropriate medical services are provided to the patients in the facility, reviewing incidents and accidents in the facility to identify hazards to human health and safety, serving as a member of the infection control committee at the facility. A review of alert charting, dated 04/05/2024 at 11:05 pm indicated a new order for permethrin 5% topical cream (a cream to treat scabies) for possible scabies treatment needs to be done…

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 have an effective Quality Assurance Performance Improvement (QAPI - a quality management program which takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality) when the committee did not develop, implement, and identify performance improvement activities related to a scabies outbreak. Refer to F 880 and F 658. This resulted in 31 residents and all staff, vendors, and visitors being at risk for exposure to scabies. Findings: A review of a facility policy titled Quality Assurance and Performance Improvement (QAPI) Program revised February 2020, indicated this facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents. Policy Interpretation and Implementation The objectives of the QAPI Program are to provide a means to measure current and potential indicators for outcomes of care and quality of life. Provide a means 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the services provided for one of 31 residents (Resident 2) met professional standards of quality during an outbreak of scabies. This resulted in a widespread scabies outbreak over a six-month period and caused pain and suffering for all residents affected by the skin sores. Findings: A review of Resident 2's medical record indicated they was admitted to the facility on [DATE], with diagnoses that included dementia, adult failure to thrive, prediabetes, and major depressive disorder. A review of the Minimum Data Set (MDS, a resident assessment) dated 04/12/2024, indicated Resident 2 has severe cognitive impairment. Resident 2 has a responsible party (RP) who makes health care decision for them. A review of skin/wound charting, dated 04/01/2024 at 1:03 pm, indicated Wound Doctor (WD) was in the facility to assess skin excoriation (a wound or scratch caused by picking at the skin) to back, chest and legs for Resident 2. WD ordered clobetasol 0.05%…

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 identify a scabies (a highly contagious skin infestation caused by human itch mites that causes intense itching of the skin) outbreak, implement appropriate precautions, monitor the effectiveness of the corrective actions and prevent further transmission when: 1. The facility's surveillance system (line listing that tracks infectious outbreaks) was incomplete. 2. Infection control committee did not monitor the scabies outbreak and evaluate the effectiveness of the corrective actions taken. 3. The nursing and housekeeping department did not implement appropriate precautions to prevent spread of scabies outbreak. 4. The staff were not trained in infection prevention and control practices to prevent further spread of scabies outbreak. 5. The facility did not take appropriate steps to diagnose and manage the resident scabies cases for two of the 31 residents. This resulted in a scabies outbreak from April to August 2024 which affected 31 residents and one…

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 safety measures were provided to prevent accident hazards for three of five residents sampled for accidents (Resident 1, 4, 8) when the wheels attached to the headboard of the bed were not locked. This failure had the potential to negatively affect the residents' well-being and increased the risk of accidents or injuries to the residents. Findings: During a review of U.S. Food & Drug (FDA) document titled, A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts , revised 4/2010 , indicated that to meet the patients' needs for safety, keep the bed in the lowest positions with wheels locked was one of the recommended practices. During a review of the American Parkinson Disease Association (APDA) website document titled, Impaired Balance and Falls in people with Parkinson's Disease , dated 6/8/21, indicated, One of the most challenging symptoms of Parkinson's disease (PD) that fundamentally…

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 treat one out of three sampled residents (Resident 1) with dignity and respect when direct care staff made Resident 1 wear an incontinent brief and would not take Resident 1 to the bathroom for toileting. This failure had the potential to result in emotional stress, anger, embarrassment, feelings of neglect, and the potential for negative clinical outcomes. Findings: During a review of the facility's policy revised 2/2021, titled, Dignity, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and esteem. This policy also indicated residents are treated with respect and dignity at all times. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This process starts with the initial admission and continues throughout the resident's facility stay. Individual…

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 a complete comprehensive care plan was developed for one of two sampled residents (Resident 1) to reflect current individual needs upon admission when: 1-Resident 1 did not have restrictions listed for staff to not use Right arm for blood pressures or any procedures for Resident 1's Right arm due to a previous mastectomy (a surgical operation to remove a breast). 2-Resident 1 did not have weight bearing restrictions listed on the care plan after a Right hip surgery. 3-Resident 1 had no interventions to monitor surgical incision site to right leg with 13 staples every shift for signs and symptoms of infection. This failure resulted in Resident 1's individual care needs to go unrecognized, and the potential for a further decline in Resident 1's physical, mental, and psychological status. Findings: 1. During a review of the facility's policy revised 3/2022, titled, Care Plans, Comprehensive Person-Centered, indicated a comprehensive,…

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 nursing staff failed to get one of two sampled residents (Resident 1) out of bed (OOB) following a hip surgery and per Resident 1's right to get OOB per request for seven consecutive days. This failure had the potential to result in emotional stress, anger, embarrassment, feelings of neglect, and the potential for negative clinical outcomes related to surgical complications of immobility for seven days. Findings: During a review of the facility's policy revised 2/2021, titled, Dignity, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and esteem. This policy also indicated residents are treated with respect and dignity at all times. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This process starts with the initial admission and continues throughout 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility nursing staff failed to complete and accurately document medical records for one of three sampled residents (Resident 1) for activities of daily living (ADLs, basic tasks completed every day that include personal hygiene or grooming, bathing, dressing, toileting, transferring or ambulating, and eating). This failure of incomplete documentation had the potential for resident needs to not be identified or met which could have a negative clinical outcome. Findings: During a review of the facility's policy revised 7/2017, titled, Charting and Documentation, indicated all services provided to the resident, progress towards care plan goals, or changes in the residents' medical, physical, functional, or psychosocial condition shall be documented in the residents' medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. During a review of the facility's policy revised…

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 notify the physician of one of three sampled residents (Resident 1) when Resident 1 had a change in condition in a timely manner. This resulted in Resident 1 not receiving timely evaluation and treatment . Findings: During a record review of document titled admission Record, Resident 1 was admitted on [DATE]. Resident 1 had a history of congestive heart failure (the heart cannot pump enough blood to meet the body ' s needs), chronic obstructive pulmonary disease (COPD, a lung disease that makes it difficult to breathe), type II diabetes (where the body cannot regulate blood sugar levels), and brain tumor. During a record review of document titled Physician Orders for Life Sustaining Treatment (POLST) status was Do-Not-Resuscitate. During a record review of facility policy titled Change in Resident ' s Condition or Status 2001 MED-PASS, a facility shall notify .attending physician on call .when there has been a significant change in the resident ' s…

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 interview, the facility failed to provide timely and accurate discharge planning for one of three residents (Resident 1) when Resident 1 was not given a 30-day notice of discharge and no physician order was received to initiate discharge planning. This failure resulted in the potential of an unsafe discharge for Resident 1 and caused him anxiety. Findings: During a record review of document titled admission Record, Resident 1 was admitted on [DATE]. Resident 1 had a history of congestive heart failure (the heart cannot pump enough blood to meet the body ' s needs), chronic obstructive pulmonary disease (COPD, a lung disease that makes it difficult to breathe), type II diabetes (where the body cannot regulate blood sugar levels), and brain tumor. Resident 1 ' s Physician Orders for Life Sustaining Treatment (POLST) status was Do-Not-Resuscitate. Resident 1 ' s Brief Interview for Mental Status (BIMS, scores on a scale of 0-15 the mental ability of an individual with 15 being 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 interview, record review, and facility policy review, the facility failed to ensure they accurately coded the Minimum Data Set (MDS) for 4 (Residents #49, #81, #59 and #58) of 6 residents reviewed for MDS accuracy. Findings included: A facility policy titled, Resident Assessments revised in October 2023, revealed A comprehensive assessment of each resident is completed at intervals designated by OBRA regulations and PPS requirements from the Minimum Data Set (MDS) is submitted to the Internet Quality Improvement Evaluation System (iQIES) as required. The policy revealed, 9. Members of the care team participate in the resident assessment process. 10. Assessments are completed by staff members who are knowledgeable about the resident's needs. 11. Persons who have competed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 1. An admission Record indicated the facility admitted Resident #49 on 02/18/2021. According to the admission Record, the resident had a medical history that included diagnoses of unspecified…

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, record review, and facility policy review, the facility failed to ensure they implemented the comprehensive person-centered care plan for 1 (Residents #58) of 23 residents reviewed for comprehensive person-centered care plans. Specifically, the facility failed to implement care plan interventions to prevent Resident #58 from wandering into other resident's rooms. Findings included: A facility policy titled, Care Plans, Comprehensive, last reviewed by the facility in October 2023, revealed, A comprehensive care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. An admission Record indicated the facility admitted Resident #58 on 03/19/2021. According to the admission Record, the resident had a medical history that included diagnoses of moderate dementia with psychotic disturbance, recurrent major depressive disorder, anxiety disorder, disorientation, and unspecified intellectual disabilities. A quarterly Minimum Data Set (MDS), with…

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, record review, and facility policy review, the facility failed to provide medically-related social services by failing to identify the need for a guardian for 1 (Resident #47) of 23 sampled residents. Findings included: A facility policy titled, Social Services, revised 10/2010, indicated, Our facility provides medically-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental or psychosocial well-being. The policy revealed, 4. The social services department is responsible for: f. Making referrals to social service agencies as necessary or appropriate. and k. Working with individuals and groups in developing supportive services for residents according to their individual needs and interests. A facility document titled, Job Description Social Services Director, prepared 03/2017, indicated, Provide medically related social services so that the highest practicable physical, mental and psychosocial well-being of each resident is attained or maintained. The job description revealed, Assist residents with…

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, record review, and facility policy review, the facility failed to have behavior monitoring for the use of an antianxiety medication, document non-pharmacological interventions prior to the use of an antianxiety medication, and have a specific duration for the use of an as-needed (PRN; pro re nata) antianxiety medication for 1 (Resident #27) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Psychotropic Medication Use, revised 10/2023, specified, Psychotropic medications will be prescribed by the physician/nurse practitioner as warranted with the goal of providing quality of life. The policy also indicated, 6. The need to continue PRN orders for psychotropic medications requires that the practitioner document the rationale for the extended order. 7. The staff will observe, document, and report to the Physician/Nurse Practitioner information regarding the effectiveness of any interventions, including psychotropic medications. The policy also indicated, 8. Nursing staff shall monitor for and report any side effects 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 observation, interview, record review, and facility policy review, the facility failed to have a medication error rate less than 5 percent (%) with a medication error rate of 13.79%. The facility had four medication errors out of 29 opportunities affecting 2 (Resident #10 and Resident #33) of 4 residents reviewed during the medication administration task. Findings included: A facility policy titled, Administering Medications, revised 10/2023, specified, Medications are administered in a safe and timely manner, and as prescribed The policy indicated, 2. Medications are administered in accordance with prescribed orders, including any required time frame. The policy revealed, 4. Medications are administered within one (1) hour before and (1) hour after the prescribed time, unless otherwise specified (for example, before and after meal orders). The policy indicated, 7. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 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.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain an infection control program to prevent the transmission/development of infection for 1 (Resident #8) of 7 residents reviewed for infection control. Specifically, the facility failed to ensure that staff implemented enhanced barrier precautions (EBP) for Resident #8. Findings included: A facility policy titled, Multidrug-Resistant Organisms [MDRO]; Infection Precaution & Enhanced Standard Precautions, revised 03/2024, revealed, a. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. An admission Record revealed the facility admitted Resident #8 on 03/27/2024. According to the admission Record, the resident had a medical history that included diagnoses of chronic respiratory failure with hypoxia and diabetes. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/28/2024,…

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 meet this requirement when a blood draw tourniquet (a device that is used to apply pressure to a limb or extremity in order to stop the flow of blood) remained on a resident (Resident 1 ' s) for an estimated six hours unnoticed and unattended to. This resulted in Resident 1 ' s hand being swollen and red, and had the potential for serious injury. Findings A review of Resident 1's clinical record, indicated Resident 1 was admitted to the facility with diagnoses including dementia (memory and mental function loss), diabetes, communication deficits (inability to speak), and muscle weakness. On 3/27/24 at 1:45 PM, Resident 1 was observed to have a phlebotomy (blood draw) tourniquet around his wrist, tied tightly in a slip knot. The tourniquet was observed to be pressing deeply into Resident 1 ' s skin; his fingers were red and swollen. There were no staff present in Resident 1 ' s room. No staff were observed to come into his room by 1:50 PM. In a concurrent interview and observation on 3/27/24 at 1:50 PM,…

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 notify the physician in a timely manner for one of three sampled residents (Resident 1) when Resident 1's urinalysis (UA, a urine specimen that determines if there is a bacterial infection in the urine) results were not obtained as ordered by the physician on 11/9/2023. The facility notified the physician that the above order was not completed on 11/17/23, seven days later. The facility failed to notify the physician in a timely manner when the second UA was sent on 11/17/2023 and the Urine Culture (a lab test to check for bacteria or other germs in a urine sample) was received on 11/19/2023. The physician was notified on 11/22/2023, three days later. These failures prevented Resident 1's attending physician from having the necessary information to determine the need to alter Resident 1's treatment. Findings: During a review of Resident 1's clinical record, indicated that she was admitted to the facility on [DATE] with diagnoses which included end…

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 follow the physician's plan of care for one of three sampled residents (Resident 1), when Resident 1 had a new physician's order for wound care treatment that was not entered to Resident 1's treatment administration record (TAR). This resulted in Resident 1 not receiving treatments as ordered by the physician and had the potential to negatively affect Resident 1's physical wellbeing. Findings: During a review of Resident 1's clinical record, indicated that she was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (a person's kidneys cease functioning on a permanent basis), dependence on renal dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), diabetes (high blood glucose), and muscle weakness. Resident 2 was her own health care decision maker. During a review of Resident 1's Minimum Data Set (MDS - 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.

Based on interview, record review and observation, this regulation was not met when two of seven sampled residents (Residents 2 and 3) received wilted, discolored salad. This resulted in the salad appearing unapalatable to both residents and did not meet the facility's policy for food storage. Findings: A review of the facility's policy titled Procedure for Refrigerated Storage indicated that Produce will be delivered frequently and rotated in the order it is delivered to assure that a fresh product is used, free of any wilting or spoilage. In an interview on 10/2/23 at 12:07 PM, Family Member 1 (FAM 1) stated that on 9/23/23 a wilted salad was served to Resident 2, her mother. FAM 1 stated that the lettuce appeared brown along its cut edges; the salad appears wilted. FAM 1 stated the salad was not fit to eat. In an interview/concurrent record review on 10/9/23 at 12:35 PM, Assistant Kitchen Supervisor A stated that a wilted/brown salad should never have gone out like that because it is unappealing. In an interview on 10/9/23 at 2:15, Resident 3 stated that there had been a brown…

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 interview, the facility failed to maintain a sanitary environment in the kitchen when: 1. There were boxes of food in the walk-in refrigerator and freezer that were not stored off the floor. 2. There was an opened box of kernel corn in the freezer. 3. There was stored food items that were undated. This failure had the potential for cross-contamination of bacteria or other microorganisms (very small organisms undetected by the eyes) to be unintentionally transferred to other surfaces and the food with a harmful effect causing food-borne illnesses for 88 residents. Findings: A policy titled, Storage of Food and Supplies dated 2017 and 2018, indicated, all food and food containers are to be stored six inches off the floor and on clean surfaces in a manner that protects it from contamination. All food will be dated-month, day, year. A review of staff competencies titled, Dietary Services Competency Pre-Test, for Dietary Staff dated 2021, indicated, food products should be labeled with the date, month, and year. A review of staff competencies titled, Safe Food…

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 provide sufficient and competent nursing staff to implement the plan of care for three of 46 sampled residents (Residents 19, 78 and 86), and five out of six confidential resident interviews when: 1. Resident 78 rolled out of bed while not having enough assistance during bed mobility (repositioning). This failed practice resulted in hospitalization for treatment of a fractured right femur. 2. Resident 19 did not have enough mealtime assistance and meal intake documentation was not accurate. This resulted in severe unplanned weight loss. 3. Resident 86 waited an extended period of time for her call light to be answered, resulting in her sitting in wet briefs for three and a half hours and embarrassment. 4. Confidential interviews indicated slow call light response. This had the potential for all resident needs not be met. 5. Oxygen equipment was not replaced by multiple staff after it was found on the floor. This put her at risk for…

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 Findings: A review of facility policy titled, Antipsychotic Medication Use, revised April 2007, indicated diagnoses alone do not warrant the use of an antipsychotic unless the following criteria are met: the behavioral symptoms present a danger to the resident or others which may include inconsolable or persistent distress for example continuous screaming and one or both of the following, symptoms are identified as being to mania or psychosis or behavioral interventions have been attempted and included in the plan of care. Based on assessing the resident's symptoms and overall situation the physician will determine whether to continue, adjust or stop existing antipyschotic medication. A review of facility policy titled, Psychotropic Medication Use, revised March 2018, indicated residents will only receive psychotropic medications when necessary to treat a specific condition, diagnosed and documented in the medical record. The physician and other staff will gather and document information to clarify 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store wasted medications in a secure container when discarded medications in Medication room [ROOM NUMBER] were not securely stored or destroyed. This failure resulted in unsecured medication waste being accessible to licensed nursing staff. Findings: A review of a facility policy titled, Medication Storage, revised 2019, indicated, Discontinued, outdated, or deteriorated drugs or biologicals are destroyed. During an interview with the Director of Staff Development (DSD) in Med room [ROOM NUMBER], on 12/01/2021 at 9:40 AM, DSD stated all wasted narcotics and controlled substances were stored by the Director of Nursing (DON), and all other medications that were wasted were stored in an incineration box in Med room [ROOM NUMBER]. In a concurrent observation, it was noted the incineration box was a tall blue sharps (needles and syringes) bin with a wide unsecured opening on the top of the bin. It was observed that some medications at 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and review of facility documents, the facility failed to provide food and drinks at a palatable temperature for four residents in a confidential interview and four sampled residents (Resident 48, 76, 83 and 295). These failures have the potential to lead to residents experiencing decreased pleasure and lead to negative clinical outcomes and further compromising the nutritional and medical status of residents. Findings: 1. Resident 48's record was reviewed. Resident 48 was admitted to the facility on [DATE], with diagnoses that included, difficulty walking, muscle weakness, open wound of abdominal wall, and Obesity. The most recent Minimum Data Set (MDS, a standardized resident assessment) dated 9/28/21 indicated, that Resident 48 was cognitively intact (able to think and reason). During an interview on 11/29/21 at 9:00 a.m., with Resident 48, Resident 48 stated the eggs are cold and the toast is chewy most mornings. 2. Resident 76's record was reviewed. Resident 76 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 interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify and implement plans of action to correct deficiencies for: 1. Resident 19's severe unplanned weight loss. These failures resulted in severe weight loss for Resident 19 at put her at risk for further health decline. Refer to F692. 2. Dietary services did not meet the nutritional needs of the residents. These dietary service failures put all residents for nutritional deficits that could contribute to possible unplanned with loss and health decline. Refer to F803, F804, F806, and F908. Findings: Review of the facility's 2021 Quality Assurance & Performance Improvement (QAPI) Plan, not dated, indicated the facility would take a proactive approach to continually improve care for residents. The facility would provide nutritious meals under the supervision of a licensed dietician, and consider resident choices and preferences for meals. The facility would put systems in place to monitor care and services, drawing data from multiple sources. The QAPI…

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 reiew, the facility failed to provide toileting care and proper storage of soiled clothing for 1 of 3 residents (Resident 86) when Resident 86 was left to wait in her soiled briefs for four hours and her soiled pajama pants were found in the resident's closet on top of her clean clothes. This failure resulted in Resdient 86 experiencing avoidable incontinence (loss of bladder control), and feeling wet and embarassed. Findings: A review of Resident 86's record indicated she was admitted to the facility on [DATE] with a diagnoses that included of diabetes mellitus (when the body does not produce enough insulin and blood sugar levels can be abnormally high) and depression. Resident 86 was her own decision maker and used a wheelchair for mobility. Resident 86 had intact cognition (able to think and reason) and required assistance with toileting, personal hygeine, mobility and dressing. A review of Minimum Data Set (MDS, a resident assessment) dated 10/22/2021, indicated…

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 safe and clean environment when: 1. Damaged ceiling tiles were observed in the laundry area and facility hallway. 2. Accumulated dust and lint was observed on the flat surfaces of the washers in the laundry area. These failures had the potential to compromise fire safety, allowing flames to penetrate through holes in the ceiling tiles in the event of a fire, and microorganisms to grow in the accumulated dust and lint. Findings: 1. Review of the Facility Assessment Tool, dated 3/9/2021, indicated the facility maintenance staff would conduct daily, weekly and monthly rounds. During a concurrent observation and interview on 12/01/2021 at 10:50 a.m. with Maintenance Director (MAINT), laundry and linen processing area was observed. A ceiling tile just inside the door was observed to be out of place with an approximate half inch crack. MAINT confirmed the out of place tile, and stated it was a fire safety issue. During a concurrent observation and interview on 12/02/21 at 8:15 a.m. with MAINT, broken…

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 and interview, the facility failed to report an injury of unknown origin for one of six residents (Resident 68) when she had a hematoma (clotted blood that forms from an injury) to her left temple and an abrasion (scrape) to her left middle finger that required evaluation at the hospital. This had the potential for delaying investigations into injuries of unknown origin by facility and required reporting agencies to be able to rule out abuse. Findings: A review of a facility policy titled, Abuse Prevention Program, revised December 2016, indicated the facility will develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of their residents. Under reporting, all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin source will be reported to the administrator to the following person or agencies, the State licensing/certification agency responsible for licensing the facility. 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 observation, interviews, and record review the facility failed to ensure one of 88 sampled residents (Resident 83) received treatment and care related to physical, occupational, and behavioral restorative therapies and not honor resident choices. This failures had the potential to result in Resident 83 not receiving individualized care needed to maintain his highest level of well-being. Findings; Resident 83's record was reviewed. Resident 83 was re-admitted to the facility on [DATE], with a diagnosis that included, Dysphagia (difficulty swallowing), neck fracture, and anxiety. The most recent Minimum Data Set (MDS, a standardized resident assessment) dated 11/19/21, indicated that Resident 83 was cognitively (ability to think and reason). During a review of Resident 83's Physician Order dated May 2021, the physician order indicated, the Nursing Rehabilitation Nurse (RNA) would apply a brace to both hands and feet seven days a week and Passive Range of Motion (PROM, someone helps move the arms and legs)…

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 provide adequate assistance to prevent avoidable accidents for one of 46 sampled residents (Resident 78), when Resident 78 rolled off her bed while being assisted by staff with bed mobility (moving from a lying position, turning from side to side, or positioning the resident while in bed). This failure resulted in Resident 78 sustaining a right femur (upper bone of the leg) fracture, and placed Resident 78 and other residents in the facility at risk of harm from potential injury, when being assisted with bed mobility without sufficient staff. Findings: Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, revised March 2018, indicated a resident's ability to perform ADL's would be measured using clinical tools, including the Minimum Data Set (MDS, a standardized assessment and care planning tool). Review of Resident 78's clinical record indicated she was admitted to the facility on [DATE] with diagnoses…

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 ensure physician ordered laboratory (lab) blood tests were implemented for one of five residents (Resident 18). This failure had the potential for Resident 18 to not receive timely treatment and/or adjustment to the medication which may cause an adverse side effect. Findings: A review of Resident 18's admission record indicated she was admitted to the facility on [DATE], with diagnoses which included Alzheimer's dementia and hypothyroidism (slow metabolism may require hormone replacement therapy). A review of the physician's orders for 11/2021, indicated Resident 18 was prescribed Synthroid (hormone replacement) 100 micrograms once daily for hypothyroidism, and Depakote (used for behaviors related to dementia) 125 milligrams once a day a bedtime. A review of the lab order dated 2/25/2021, indicated Resident 18 was to have a Complete Blood Count (CBC, blood test to check overall health) platelets (blood clotting cells) , and a comprehensive metabolic…

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, staff interviews and review of facility documents, the facility failed to ensure the menu was followed on 12/1/21 when greater than 5 residents on puree and mechanical soft diets received incorrect portion sizes for the small, regular, and large portion diets. These failures have the potential for residents to receive the wrong caloric intake when not following the menu, which could result in over nutrition or undernutrition, can result in the substitutes not being equal of nutritive value which may result in a significant weight loss and further compromising the nutritional and medical status of residents. Findings: 1. The Pureed Diet is used for individuals who have difficulty chewing and/or swallowing. Any foods from the regular diet that can be appropriately pureed should be included in this diet. Procedures should be developed for pureeing food to provide correct and adequate portions equivalent in nutritional value to the portions used in a regular diet (Maryland Department of Health, 2014). 2. The Mechanical Soft (Dental) Diet modifies the consistency 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and review of facility documents, the facility failed to ensure the menu was followed on 12/1/21 when: 1) One sampled resident (Resident 1) was not offered a protein-based substitute of similar nutritive value for eggs. 2) One sampled resident (Resident 76) was not able to receive coffee with her morning meal when repeatedly requested. 3) One sampled resident (Resident 295) was not able to receive coffee with her noon meal when repeatable requested. Failure to provide food in accordance with resident preferences may result in decreased meal satisfaction, substitutes not being equal of nutritive value, over all caloric intake, and may result in a significant weight loss and further compromising the nutritional and medical status of residents. Findings: The Vegetarian Diet is a modification of the regular diet. The diet predominantly composed of plant foods and may or may not include eggs and dairy. The vegetarian Diet should provide a variety of foods that ensure adequate…

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 replace a contaminated oxygen mask (mask worn over the mouth and nose) for one two sampled residents when Resident 46's oxygen mask and tubing was found on the floor. This failure placed Resident 46 at risk for infection. Findings: Review of the admission record indicated Resident 46 was admitted to the facility on [DATE], with the diagnosis of chronic obstructive pulmonary disease (COPD, a disease that affects the lungs, making it hard to breath over time). Review of the General Order dated 9/24/2021, indicated Resident 46 was to be placed on two liters of oxygen as needed. Review of the General Order dated 10/18/2021, indicated Resident 46 had an order for ipratropium-albuterol 0.5 milligram-3 milligram respiratory treatments (liquid medication that is breathed into the lungs with use of a machine and oxygen mask) every six hours for shortness of breath. During an observation on 11/30/2021 at 8:42 am, Resident 46 had a respiratory…

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 and interview, the facility failed to ensure the plate warmer was in full operational capacity. This failure resulted in three sampled residents (Resident 48,76, and 83) and four residents in a confidential interview with the potential for all 84 of the facility's residents to get served cold food at a unpalatable temperature, leading to residents experiencing decreased pleasure and further compromising the nutritional and medical status of residents. Findings: Resident 48's record was reviewed. Resident 48 was admitted to the facility on [DATE], with diagnoses that included difficulty walking, open wound of abdominal wall, and obesity. The most recent Minimum Data Set (MDS, a standardized resident assessment) dated 9/28/21 indicated, that Resident, 48 was cognitively intact (able to think and reason). During an interview on 11/29/21 at 9:00 a.m., with Resident 48, Resident 48 stated the eggs are cold and the toast is chewy most mornings. Resident 76's record was reviewed. Resident 76 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.