Valley Oaks Post Acute

Based on observations, interviews, facility policy review, and review of the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure dishware was allowed to air dry before being stacked in 1 of 1 facility kitchen. Stacking the dishes while still wet/damp had the potential to create an environment conducive to microbial growth, which could result in foodborne illness. The failed practice had the potential to affect all 51 residents who resided in the facility and received meals from the kitchen. Findings included: An undated facility policy titled Dishwashing indicated, Dishes are to be air dried in racks before stacking and storing. The U.S. FDA 2022 Food Code requirement for drying equipment and utensils indicated, Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. On 12/17/2024 at 10:10 AM, Dietary Aide #2 was observed to stack three visibly wet dessert bowls on a tray on top of each…

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, records reviews, and facility policy review, the facility failed to ensure an evaluation for causative factors was conducted and documented after each fall to facilitate the ability to develop effective fall prevention interventions and failed to ensure accurate information about residents' falls was maintained for 2 (Resident #36 and Resident #25) of 2 sampled residents reviewed for accidents. Findings included: A facility policy titled, Fall Risk Assessment, revised 03/2018, indicated, 9. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. A facility policy titled, Falls and Fall Risk, Managing, revised 03/2018, indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent resident from falling and to try to minimize…

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, record review, and facility document review, the facility failed to ensure the quality assessment and assurance (QAA) committee developed and implemented appropriate plans of action to correct and identify quality deficiencies related to evaluation, tracking, and documentation of falls to facilitate the ability to identify any patterns, determine causal factors, and enable the facility to ascertain whether appropriate and effective interventions were implemented for 2 (Resident #25 and Resident #36) of 2 residents reviewed for falls. Findings included: The facility's Quality Assurance Performance Improvement (QAPI) Plan 2024, dated 01/2024, indicated, Feedback, Data Systems, and Monitoring a. Describe the overall system that will be put in place to monitor care and services, drawing data from multiple sources. The plan also specified several sources of data that would be monitored through QAPI, one of which was, Adverse events (incident reports, 24 hour report) and indicated that 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, record review, facility document review, facility policy review, and review of the Centers for Disease Prevention and Control (CDC) guidelines, the facility failed to ensure staff adhered to contact isolation precautions and donned the appropriate personal protective equipment while performing care or services in the room of a resident (Resident #26) with a known communicable disease (Clostridium difficile [C. diff]), to prevent the potential spread of C. diff infection to other residents. The failed practice was identified for 1 (Resident #26) of 1 resident reviewed for transmission-based precautions (TBP) and had the potential to affect 14 other residents who resided on the East Hall and were likely to receive care from staff assigned to Resident #26. Findings included: An undated facility policy titled, Standard and Other Precautions, indicated, Contact Precautions The following is adapted from CDC publication 2007 Guideline for Isolation Precautions: Preventing Transmission of Infections Agents in Healthcare Settings, which can be obtained at…

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

Based on interviews, record review, and facility policy review, the facility failed to provide residents with access to their personal funds on weekends for 1 (Resident #20) of 5 residents sampled for personal funds . Findings included: A facility policy titled, Deposit of Resident Funds, revised 03/2021, revealed 1. Should the resident permit the facility to hold, safeguard, and manage his or her personal funds, the facility will: c. provide the resident access to funds of fifty (50) dollars or less within twenty-four (24) hours, and access to funds in excess of fifty (50) dollars within three banking days. 2. Funds not on deposit in the resident's account are deposited into the resident petty cash fund managed by the facility on behalf of the residents. The State Operations Manual (SOM) Appendix PP - Guidance to Surveyors for Long Term Care Facilities guidance at tag F567 indicated, Resident requests for access to their funds should be honored by facility staff as soon as possible but no later than: - The same day for amounts less than $100.00 ($50.00 for Medicaid residents); -…

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

Based on record review and interview, the facility failed to submit the findings of an alleged abuse investigation to the State Survey Agency (Department) within five working days of the incident. This failure had the potential to compromise resident's health and safety, and delay necessary actions to protect residents from abuse. Findings: Review of a facility report incident (FRI) submitted by the facility to the Department dated 9/30/24, indicated, an alleged abuse incident involving two residents, (Residents 1 and 2) that occurred on 9/29/24 at 5:30 p.m. The FRI indicated, [Resident 2] was yelling because [Resident 1] was in his bed. [Resident 1] kicked at [Resident 2] and made contact with his leg. During an interview on 9/30/24 at 3:22 p.m. with the facility's administrator (ADM), the ADM confirmed an alleged abuse incident occurred on 9/29/24. The ADM indicated there would be an investigation into the incident between Residents 1 and 2. During an interview on 11/18/24 at 12:10 p.m. with the ADM, the ADM stated the investigation was completed but the results were not submitted…

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 Minimum Data Set ([MDS] a standardized tool that measures health status in nursing home residents) assessment accurately reflected the residents status for one of three sampled residents (Resident 1). This failure resulted in the documentation of inaccurate assessments and had the potential for Resident 1's identified care needs to go unmet. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including, dementia (loss of cognitive functioning; thinking, remembering, and reasoning and interferes with a person's daily life and activities), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), depression (a persistent feeling of sadness and loss of interest in activities) and hypertension (high blood pressure). During a review of Resident 1's admission MDS - Section E -Behavior, dated 10/12/22, the MDS indicated, Physical behavioral symptoms directed toward others (e.g., hitting, kicking,…

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 follow their policy and procedure (P&P) to review and revise a person-centered comprehensive care plan for one of three residents (Resident 1) who exhibited aggressive behavior towards other residents. This failure resulted in Resident 1 becoming aggressive and kicking another resident (Resident 2) in the leg and had the potential to place other residents at risk for serious injury. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including Dementia (loss of cognitive functioning; thinking, remembering, and reasoning and interferes with a person's daily life and activities), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), depression (a persistent feeling of sadness and loss of interest in activities) and hypertension (high blood pressure). During a review of Resident 1's Nursing Progress Notes (NPN), dated 9/18/24, the NPN indicated, Change in Condition . Physical aggression, Verbal…

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 staff implemented its policy and procedure (P&P), Activity planning and Procedures for the Activity Director, (undated), for 40 of 40 sampled residents when: 1) residents did not receive a written evaluation as to their abilities to participate in activities and signed by a physician; 2) residents did not receive an individual activity treatment plan based on their individual likes and preferences; and 3) there was no documentation of individual problems, needs, and goals in any of the 40 resident's medical records. These cumulative failures have the potential to result in physical and psychosocial harm to residents and a reduction in achieving and/or maintaining their highest level of mental and physical well being. Findings: During a review of the facility's policy and procedure (P&P) titled, Activity Planning and Procedures for the Activity Director, (undated), the P&P indicated: Purpose: To fulfill the social, psychological, and physical needs of the patients. To return them to reality and prevent…

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 sanitation were implemented when: 1) Two of two buckets containing sanitizing solution was not at an effective concentration to sanitize a food contact surface. 2) The ice machine was not maintained in a sanitary manner. 3) The temperature monitoring log for the refrigerator, located at the nursing station, was greater than 41 degrees Fahrenheit (F) multiple times in which the staff failed to identify and report for immediate remedy. These failures had the potential to place the residents at an increased risk of foodborne illness. Findings: 1. During a concurrent observation and interview on 2/8/22, at 11:03 a.m., with Dietary Aide (DA) 2, in the kitchen, DA2 was observed wiping down a food utility cart with a cloth. DA2 stated, the cloth was from a red bucket that contained sanitizer. DA2 checked the concentration of the sanitizer; opened a new package of chem (chemistry) test strips (measures the concentration of sanitizer in solution) and tested the quaternary sanitizing…

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 post a copy of the facility's grievance procedure on the resident bulletin board as required in its policy and procedure titled, Grievances/Complaints, Filing, dated April 2017. This facility failure has the potential for: 1) all residents or resident representatives not knowing how to file a grievance/complaint and resident's issues not being heard or resolved; and 2) not properly documenting and recording resident grievances in the, Resident Grievance Complaint Log. Findings: During a review of the facility's policy and procedure (P&P) titled, Grievances/Complaints, Filing, dated April 2017, the P&P indicated: Policy statement - Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g , the State Ombudsman) .Policy Interpretation and Implementation (4) .A copy of our grievance/complaint procedure is posted on the resident bulletin board. During an interview on 2/9/22, at 4:20 p.m., with 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 the activity director (AD) had the required qualifications and experience per the facility job description titled, [Name of Facility] Activity Director Job Description, (undated). This failure has the potential to result in physical and psychosocial harm to residents. Findings: The facility job description, [Name of facility] Activity Director Job Description , (undated) indicated: Position - Under the direction of the administrator and/or the director of nursing services develops, implements, and supervises the activity program and maintains required record . 1. Qualifications - .and shall receive consultation by an occupational therapist, occupational therapist assistant, or recreation therapist who has at least 1 year of experience in a health care setting. Examples of Duties: Develops, implements, and supervises all the activity programs and recreation of the facility and coordinates the activity schedule with other patient services . Evaluates each patient to plan a meaningful program . Maintains…

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 develop a policy and procedure to ensure safe and sanitary storage, handling, and consumption of food items when food was stored in a designated refrigerator, adjacent to the nursing station, that could include food brought to residents by family and visitors. This failure has the potential for unsafe food storage, handling, and consumption that could place the residents at an increased risk of foodborne illness. Findings: During an interview on 2/8/22, at 11:35 a.m., with Certified Nurse Assistant (CNA) 2, CNA2 stated, when family brings in food from outside, they give it to the Charge Nurse to put it away in the refrigerator in the medication storage room. During a concurrent observation and interview on 02/08/22, at 11:39 a.m., with Assistant Director of Nursing (ADON), located at the refrigerator in the medication room, at the nursing station, ADON stated that is the refrigerator where food brought to residents by family or visitors would be stored. The refrigerator had an electronic temperature…

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 its policies and procedures (P&P) on COVID-19 (a respiratory infection caused by the SARS-Cov 2 virus) infection prevention and control were followed when: 1) the facility did not properly screen the State/Federal survey team for COVID-19 upon entry at the facility's north wing entrance; and 2) LN4 did not follow the facility's polices and procedures (P&P), Infection Prevention and Control Measures, and Administering Medications, during medication administration to two sampled residents (Residents 36 and 41) who were on transmission-based precautions (TBP) in the facility's designated COVID-19 quarantine zone. These failures had the potential to spread COVID-19 to residents, staff and/or other visitors going in and out of the facility. Findings: 1) On 2/8/22 at 10:15 a.m., the State/Federal survey team, arrived at the facility to conduct its required annual federal recertification survey. The survey team entered the facility through the north wing entrance which directly accessed the main nurses'…

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 two of 12 sampled residents (Residents 36 and 41) were provided reasonable accommodation for the use of the facility's call light system. This facility failure had the potential for the residents not to have their needs met. Findings: 1) During a review of Resident 41's, admission Record (AR), dated 9/30/19, the AR indicated, Resident 41 was admitted with diagnoses including, Urinary Tract Infection (UTI - infection in any part of the urinary system), Hemiplegia/Hemiparesis (paralysis to one side of the body), and Pressure Ulcer of Sacral Region, Stage 4 (deep, extensive wound of the lower back). During a concurrent observation and interview on 2/8/22, at 10:42 a.m., with Resident 41, the resident was observed in bed, with eyes closed, but arousable when name was called. Resident 41 had a slight contracture (a permanent shortening of a muscle or joint) of the left arm, had arthritic (swelling and tenderness of one or more joints) fingers on both hands, and had suffered a stroke (a medical emergency…

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 complete a Change of Condition (COC - a system for identifying, evaluating, and reporting when resident's condition changed) per their policy and procedure for one of 12 sampled residents (Resident 35) when Resident 35 fell. This facility failure had the potential for vulnerable residents to not receive appropriate care, decline in their functional mobility, and development of skin breakdown and have a delay in treatment and services. Findings: During a review of the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status, dated May 2017, the P&P indicated, Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR (a tool to help in facilitating communication between nurses and prescribers) Communication Form. During a concurrent interview and record review, on 2/9/22, at 11:35 a.m., with Minimum Data Set Coordinator…

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 proper and alternative means of communication for translation services for one of 12 sampled residents (Resident 16). This facility failure has the potential for Resident 16's physical and psychosocial needs not being met. Findings: During an observation and interview on 2/8/22, at 1:45 p.m., with Resident 16 in the resident's room, Resident 16 was only able to communicate in Spanish. There were no other means of communication observed in the resident's room. During an interview on 2/8/22, at 2 p.m., with Certified Nursing Assistant (CNA), the CNA stated, she was the only Spanish speaking staff member at that time but was not assigned to Resident 16. The CNA further stated, whenever they needed translation for Resident 16, she would be called to do so, but is not readily available all the time. During an interview on 2/16/22, at 8:20 a.m., with the Director of Nursing (DON), the DON confirmed there was no adequate system in place to communicate with non-English speaking residents. The DON further…

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 its medication error rate during staff medication administration was less than five percent. The facility had a cumulative medication error rate of eight percent when 2 errors of 25 opportunities for errors, were observed between two licensed nurses who administered medication, to one unsampled resident (Resident 42) and 1 of 12 sampled residents (Resident 41). The observed medication administration errors were: 1) Resident 42's medication order of Carafate Suspension (Sucralfate - medication used to treat and prevent ulcers in the stomach) was to be administered before meals and at bedtime. A licensed nurse (LN3) administered the medication after Resident 42 had eaten breakfast; 2) Resident 41's medication order of Juven (a therapeutic nutrition powder for wound healing) powdered supplement was to be mixed in eight oz. (ounces) of fluid before administration. LN4 did not measure the fluid that was mixed with the powdered supplement. These findings had to potential for adverse consequences 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.

Based on observation, interview, and record review, the facility failed to ensure its medication error rate during staff medication administration was less than five percent. The facility had a cumulative medication error rate of eight percent when 2 errors of 25 opportunities for errors, were observed between two licensed nurses who administered medication, to one unsampled resident (Resident 42) and 1 of 12 sampled residents (Resident 41). The observed medication administration errors were: 1) Resident 42's medication order of Carafate Suspension (Sucralfate - medication used to treat and prevent ulcers in the stomach) was to be administered before meals and at bedtime. A licensed nurse (LN3) administered the medication after Resident 42 had eaten breakfast; 2) Resident 41's medication order of Juven (a therapeutic nutrition powder for wound healing) powdered supplement was to be mixed in eight oz. (ounces) of fluid before administration. LN4 did not measure the fluid that was mixed with the powdered supplement. These findings had to potential for adverse consequences 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.

Based on observation, interview, and record review, the facility failed to keep an unattended medication cart locked while parked at the nursing station. This facility failure has the potential for residents and/or visitors to have access to medications that could lead to adverse complications. Findings: During an observation on 2/8/22, at 3:35 p.m., at the central nursing station, an unattended medication cart was found to be parked on the side. The medication cart was unlocked and a drawer was able to be opened without resistance. During an interview on 2/8/22, at 3:41 p.m., with Licensed Nurse (LN) 2, LN2 stated, she forgot to lock the medication cart after use, before leaving it on the side of the nursing station. LN2 acknowledged the medication cart should be locked when not in use. During an interview on 2/16/22, at 8:15 a.m., with the Director of Nursing (DON), the DON stated, the medication cart should be locked at all times, when not in use or unattended. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated April 2019, the P&P…

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 dental services to 1 of 12 sampled residents (Resident 38). This resulted in Resident 38 not having teeth to chew food, having to be put on a modified diet, and has the potential for weight loss and poor self-image. Findings: During a review of the facility policy and procedure (P&P) titled, Dental Examination/Assessment, dated December 2013, the P&P indicated: Policy Statement 1. Resident shall be offered dental services as needed . 4. Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist. During a review of Resident 38's admission Record, the record indicated, Resident 38 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia with behavioral disturbance (disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). During a review of Resident 38's Order Summary…

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 cook (Cook1) was competent on internal cooking temperatures for ground beef and poultry to ensure food safety. This failure placed the residents at risk of a foodborne illness. Findings: During an interview on 2/8/22, at 3:39 p.m., with [NAME] (Cook1) and the Dietary Service Manager (DSM), [NAME] 1 stated, I just look at it (ground beef) to determine the meat is done. The DSM stated, a thermometer should be used to check for internal cooking temperatures to determine when food is thoroughly cooked. During an interview on 2/8/22, at 4:10 p.m., with [NAME] (Cook1), Cook1 stated, I would cut open the chicken and check temperature to read above 160 (degrees Fahrenheit [F]. During an interview on 2/8/22, at 4:12 p.m., with the DSM, the DSM stated, the internal temperature of ground beef should be 155 degrees F and chicken should reach an internal cooking temperature of 165 degrees F. The DSM stated, she would expect a cook to be competent on internal cooking temperatures for food safety. During a review of 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 follow the menu as planned when: 1. A fortified menu item was not served for 1 of 12 sampled residents (Resident 23) as directed on the meal tray card. 2. The menu for a therapeutic renal diet was not followed for 1 of 12 sampled residents (Resident 36). These failures had the potential to not meet the residents nutritional needs per the planned menu as approved by the facility's Registered Dietitian. Findings: 1. During a concurrent observation and interview on 2/9/22, at 11:43 a.m., with Dietary Aide (DA) 1, in the kitchen, DA1 removed Resident 23's tray from the meal delivery cart and reviewed Resident 23's meal tray ticket that included, fortified, regular diet. DA1 asked the cook what the fortified item was, and the cook (Cook1) stated, I can give two pats of butter. Concurrently, the Dietary Services Manager (DSM) observed Resident 23's meal tray that was removed from the meal delivery cart and confirmed there should have been two pats of butter and the fortified menu item for the fortified diet was not…

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.