Aviata At The Sea - Harbor Beach

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and chart review, the facility failed to provide food in a form to meet the needs of 2 of 2 residents on the Dysphagia advanced diet (Resident #55 and Resident #10). This has the potential to affect three residents on a Dysphagia advanced diet.The findings included:A review of the National Dysphagia Diet Levels was provided by the Kitchen Manager. The following was noted: Level 3 Dysphagia advance is characterized by a mechanical soft texture, such as moistened ground meats and fork-mashable fruits and vegetables. A chart review revealed that Resident #55 was admitted to the facility on [DATE] with diagnoses of Dementia and Dysphagia following a Cerebrovascular Disease. In an observation conducted on 09/08/2025 at 12:13 PM in the main dining area, Resident #55 was eating her lunch meal. The meal ticket was noted as follows: Dysphagia advanced diet, chopped roasted broccoli florets, chopped ground bruschetta chicken, parmesan noodles, dinner roll, sour cream, orange cake, 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, and record review, it was determined that the facility failed to dispose of garbage and refuse properly in 2 of 2 observations. The findings included: A review of the facility's policy titled Solid Waste Management dated 11/30/2014 showed the following: solid waste shall be handled and disposed of in a manner that shall ensure a safe and sanitary facility environment. An observation was conducted on 09/08/25 at 8:39 AM outside the main dumpster. Two large blue dumpsters were partially open, with numerous bags of garbage/trash broken open and spilling their contents outside the dumpsters. Further observation showed garbage, trash, medication containers, and medical waste products on top of the blue dumpsters. Further observations showed protective Equipment, gloves, and surgical masks were noted all around the garbage area. On 09/09/25 at 8:45 AM, an observation was conducted in the outside dumpster area, where one blue dumpster was found to be unsealed and contained garbage bags, food boxes, disposable plates, and other trash. The area around 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 observations, interviews and record reviews, the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBP) for 2 of 15 EBP residents (Resident #4 and Resident #22). The findings included: According to the Center for Disease Control and Prevention (CDC), Enhanced Barrier Precautions sign post included the following: Everyone must clean their hands, including when both entering and leaving the room: Providers and Staff must also wear gloves and a gown for the following: high-contact care resident care activities, dressing, bathing-showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting: Device care or use; central line, urinary catheter, feeding tube, tracheostomy: Wound care with any skin opening requiring a dressing. https://www.cdc.gov/long-term-care facilities/media/pdfs/ 1) A record review documented Resident #4 was admitted to the facility on [DATE] with diagnoses that included…

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 review of policy and procedure, record review and interview, the facility failed to ensure that it followed physician's order for Intravenous (IV) antibiotic administration for 1 of 3 sampled residents observed, Resident #1. The findings included: Record review of the facility policy and procedure titled Physician's Orders provided by the Director of Nursing (DON) revised 03/03/21 documented in the Policy Statement: The center will ensure that Physician's orders are appropriately and timely documented in the medical record. Procedure: admission Orders: Information received from the referring facility or agency to be reviewed, verified with the physician and transcribed to the electronic medical record .Routine Orders: A nurse may accept a telephone order from the Physician, Physician Assistant or Nurse Practitioner .For pharmacy orders, the nurse will notify the pharmacy per pharmacy policy by telephoning, faxing or completing the order electronically .to maintain an accurate medical record. Record…

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, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 16 of 28 resident rooms, 1 of 2 community shower rooms, main dining room, ice machine room, and 1 of 1 clean linen storage rooms. The findings included: 1) During the observation of the commercial ice machine room which is located in a room just off the main dining room on 05/07/24 at 1 PM accompanied with the Corporate Housekeeping Director (CHD). The floor of the entire room was heavily soiled and stained black in color. Further noted the floor area was missing around the commercial ice machine and there was a large gap under the exit door to the outside that could potentially allow entrance of pests into the facility. Photographic Evidence Obtained. 2) During the observation of the facility's laundry room department on 05/07/24 at 2 PM and on 05/08/24 at 2 PM, accompanied with the facility's Corporate Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, 5 of 14 sampled residents (Resident #4, Resident #14, Resident #19, Resident # 30, and Resident # 33) were noted to be treated in an undignified manner by the facility. The findings included: 1) On 05/06/24 at 1:44 PM, Resident #14 was observed sitting in a wheelchair appropriately dressed in his personal attire. Resident #14's feeding formula was infusing via a tube. The privacy curtain dividing Resident #14 from his roommate, who also was observed in bed eating lunch, was fully opened. Resident #14 could easily see Resident #33's meal and did see Resident #33 eating his lunch. Resident #14 was admitted to the facility on [DATE]. Resident #14 diagnoses included: Cerebral Infarction and Flaccid Hemiplegia affecting right non-dominant side. Resident #14 is fed via peg tube. He is non-verbal and communicates using facial gestures, his hands, and head (nodding yes or no). Resident #14 gestured his displeasure on 05/06/24 at 1:47 PM to question, how do you feel watching your…

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 records review and interviews, the facility failed to investigate an incident in which 1 of 1 sampled resident (Resident #15) sustained injuries of unknown origin. The findings included: Resident #15's electronic clinical record revealed he was readmitted to the facility on [DATE] and an initial admission date of 3/5/2024. Resident #15 diagnoses included: Dislocation of left shoulder joint; Anxiety Disorder; Atherosclerotic Heart Disease; Type 2 Diabetes Mellitus; Osteoarthritis; Muscle weakness; Cognitive communication deficit; Difficulty walking; Convulsion; Depression; Localized swelling to left upper limb; History of falling. The Nurses' Progress Notes (NP's) dated 4/14/2024 at 7:07 AM, noted that Resident #15 was complaining of left-hand pain and swelling. the MD was notified, and an X-Ray was ordered. Another NP's notes dated 4/15/2024 documented that order received to send the resident to hospital for higher level of care and altered mental status. The 4/16/2024 NP's notes revealed that Resident…

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, it was determined that the facility failed to provide assistance and supervision to maintain independent eating abilities for 2 (Resident #5 and #13) of 6 sampled residents reviewed for nutrition. The findings included: 1) During the observation of the breakfast meal of 05/08/24 at 8:30 AM, it was noted that the meal tray was observed to be delivered to the room of Resident #5. Continued observation noted that the resident was visually impaired but alert. Continued observation noted that the Certified Nursing Assistant (CNA- Staff E) set the tray on the resident's overbed table in front of the resident who was noted to be in a reclining position in the bed. The CNA failed to speak with the resident concerning where foods could be located on the meal tray or reposition the resident into an upright eating position in the bed. Further observation noted the CNA to leave the room and not return to give the resident supervision or assistance with the meal. 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 identify and treat a resident with Diabetes for 1 of 1 resident reviewed for insulin (Resident #17). The findings included: Resident #17 was admitted to the facility on [DATE] with diagnoses which included Diabetes Mellitus Type 2 and a Diabetic foot ulcer. A comprehensive assessment dated [DATE] documented the resident was cognitively intact (15/15 Brief Interview for Mental Status), and required partial/moderate assist for activities of daily living. The assessment further documented Resident #17 had not received any injections (insulin) since admission to the facility. Record review revealed Resident #17 was care planned for Diabetes, with an intervention to medicate as ordered. A review of Resident #17's orders on 05/08/24 revealed Resident #17 did not have any medications for Diabetes, nor any fingersticks or lab results indicating the resident's blood sugar levels. An interview was conducted with Resident #17 on 05/08/24 at 11:00…

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

Based on observations, records review, and interviews, the facility failed to provide physician's ordered left hand splint to 1 of 1 sampled resident (Resident #14). The findings included: On 05/06/24 at 12:48 PM Resident #14 was observed in bed lying in supine position with contracted left hand and having no splint on. Resident #14 was alert, aware, but non-verbal. Review of the physician's orders dated 12/17/2022 revealed the following order: left hand splint to be worn up to 6 hours, 7 days a week. Apply left elbow splint up to 6 hours 7 days a week. Another order noted: Left Elbow Splint as tolerated, may remove for ADL care or skin checks. Also, Resident #14 to wear Carrot on left hand at all times except for hand hygiene and bathing. Resident #14's diagnoses included, Hemiplegia and hemiparesis following Cerebral Infarction Affecting left non-dominant side; Muscle weakness generalized; Amyotrophic lateral sclerosis; Contracture left ankle; Anxiety Disorder; Ankylosis left wrist; Mild Cognitive impairment of unknown etiology; Ataxia; Irritant Contact Dermatitis; Progressive…

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 Physician failed to identify and treat a resident with Diabetes for 1 of 1 resident reviewed for insulin (Resident #17) and failed to address a critical lab result for 1 of 1 sampled resident (Resident #157). The findings included: A review of the facility's Policy and Procedures Medical Care/Standards of Practice, dated 11/30/2014 and revised on 03/03/21, documented: A physician supervises the medical care of each resident. Physician supervision includes but is not limited to: admission orders are consistent with the resident's current physical and mental status. No medications or treatments shall be given without a doctor's order. Whenever possible, each of the resident's clinical problems should be clearly identified in the progress notes and correlate with specific orders as well as results of tests and treatments. 1. Resident #17 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus Type 2 and a Diabetic foot ulcer. 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 record review and interview, the facility Physician failed to document visits in a timely manner for 2 of 2 sampled residents (Resident #17 and Resident #157). The findings included: A review of the facility's Policy and Procedures Medical Care/Standards of Practice, dated 11/30/2014 and revised on 03/03/21, documented: Physician visits are required according to the resident's needs and/or State and Federal guidelines. A physician visit is required within 48 hours of admission. For short term care, a physician must see the resident as often as medically necessary according to the medical status of the resident. It is recommended physician visits occur two or three times per week due to the medical complexity of the resident. Medical records must be maintained according to all state and federal requirements and in compliance with all center policies and procedures. The attending physician shall maintain his portion of the medical record, timely, in accordance with the center, State and Federal…

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, it was determined that the facility failed to prepare pureed foods by methods that conserve nutritive, value, flavor, and appearance for 4 (Residents #5, #7, #19, and #30) of 4 residents with physician ordered Pureed Diet with Pureed Fortified Foods. The findings included: During the observation of the lunch meal in the main kitchen on 05/06/24 at 11:30 AM, foods located on the steam table were observed and were taste tested by the surveyor. Specifically, the Pureed Cheese Ham & Macaroni Casserole, and Pureed Sauteed Spinach noted to be very thin and watery in consistency. The taste test confirmed that the pureed foods were too thin and had a watery consistency. Interview with the Lunch [NAME] (Staff C) at the time of the observation was noted to state she was unaware that the addition of too much liquid into the pureed food mixture results in decreased nutritional value of the pureed foods, and negative appearance and taste palatability. Staff C stated no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain the hot water temperature at an acceptable level for the safety of the residents observed during an Environmental tour for 7 rooms out of 20 rooms occupied. The findings included: The policy titled, Monitoring and Recording Facility Hot Water Temperatures for Residents' Rooms, Common Areas, and Shower Rooms, dated 11/30/2014, showed to maintain and control hot water temperatures within the facility to federal and state standards. Hot water temperatures will be maintained at an acceptable level for the safety of the residents and staff. The following procedures will be implemented, by the Maintenance staff, if a hot water temperature is found to be above 110 degrees Fahrenheit, the acceptable level for resident rooms, showers, and common areas: (If high temperature is found on the weekend or holidays, immediately call the maintenance staff). In a tour conducted on 02/22/23 from 10:44 AM to 12:00 PM, the following rooms were…

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 review of policy and procedure, observation, interview and record review, it was determined that the facility failed to 1) ensure that it properly kept a resident covered in a dignified manner, 2) failed to ensure that it referred to a resident in a dignified manner, 3) failed to ensure that it promptly provided feeding assistance to a dependent resident during the lunch meal, 4) failed to ensure that it maintained the resident's Foley catheter in a dignified manner, 5) failed to provide meal trays to all residents at the same time ; and, 6) failed to sit at eye level during dining assistance. This deficient practice affected 5 of 19 sampled residents reviewed for dignity. (Resident #3, Resident #10, Resident #36, Resident #7 and Resident #23). The findings included: Review of the facility policy and procedure 02/23/23 titled, Policies and Procedures---Urinary Catheter Care provided by the Director of Nursing (DON) revised 09/05/17 documented in the Policy Statement: Procedure Provide privacy . Review…

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 interviews, the facility failed to provide wound care consistent with professional standards of practice to prevent infection and to follow physician's order for wound care for 1 of 1 sampled residents reviewed for pressure ulcers (Resident #6). The findings included: Review of the facility's policy titled Dressing Change revised on 12/06/17 and policy titled Skin and Wound revised on 01/24/22 revealed the policy did not address wound care technique. Review of Resident #6's clinical record documented an initial admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Diabetes Mellitus, Cognitive Communication Deficit, Anemia, and Alzheimer's. Review of Resident #6's Minimum Data Set (MDS) annual assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 8, indicating that the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed supervision to limited…

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 interviews, and record review, the facility failed to provide nutritional intervention and assessment in a timely manner for 1 of 3 sampled residents reviewed for nutrition (Resident #35). The findings included: The facility's policy titled, Medical Nutrition Therapy Assessment and Care Planning, revised on 09/2017, showed that a Registered Dietitian is responsible for completing a comprehensive nutritional assessment to identify and plan the nutrition care based on the needs, goals, and preferences of each Resident. In an interview conducted on 02/23/23 at 2:20 PM, Resident #35 was observed in her bed resting. She stated that she had gained some weight, had a great appetite, and was always hungry. Resident #35 noted that the Clinical Dietitian has yet to speak to her to obtain food likes and preferences or any additional snacks between meals. She further said that she likes coffee/mocha flavor shakes and Boost but that the facility does not offer these flavors or options. A record review showed 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 observations, interview and record review, the facility failed to monitor and to follow the physician orders for Tube feeding for 1 of 1 sampled residents reviewed for Tube Feeding (Resident #21). The findings included: Review of the facility's policy titled, Enteral Feeding- Enteral Nutrition Pump revised on 11/12/18 documented Nurses administer enteral feeding when volume control is indicated and as ordered by physician Review of Resident #21's clinical record documented an initial admission to the facility on [DATE] with a latest readmission on [DATE] . The resident's diagnoses included Parkinson's, Chronic Kidney Disease, Heart Disease, Dementia, Pain, Muscle wasting, Displaced Mid-cervical fracture of left femur with closed fracture routine healing and Anemia. Review of Resident #21's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 11, indicating that the resident had moderate cognition impairment. The assessment documented…

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 review of policy and procedure, observation, interview and record review, it was determined that the facility failed to 1) ensure that it secured over-the-counter (OTC) cream medication for 2 sampled residents observed, Resident #3 and Resident #37. 2) failed to ensure that it promptly secured the facility's Emergency medication box (E-kit) after use, during a Medication Administration Observation, for 1 of 1 Medication Storage Rooms, 3) failed to ensure that it discarded two expired stock OTC betadine swab stick packages in the facility's Medication Treatment Cart, 4) failed to ensure that it secured the facility's Treatment Medication Cart during Wound Care Observation; and 5) failed to secure routine medication during Medication Administration Observation, Resident #21. The findings included: Review of the facility policy and procedure on [DATE] at 4:21 PM titled LTC Facility's Pharmacy Services and Procedures Manual Storage and Expiration Dating of Medications, Biologicals [DATE]. provided by 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 observations, interviews, and record review, the facility failed to provide food and drink that is palatable, attractive, and at a safe and appetizing temperature for three residents during dining observations (Resident #7, Resident #3, and Resident #13). The findings included: 1. In an observation conducted on 02/22/23 at 7:55 AM, the first meal cart arrived on the unit. The breakfast tray was taken into Resident #7 ' s room and placed on the bedside table. Continued observation showed that at 8:25 AM, which was 30 minutes later, staff came into the room to assist Resident #7 with her breakfast meal. A record review showed that Resident #7 was admitted on [DATE], and the Minimum Data Set (MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 7, which is cognitively impaired. Section G for eating showed that Resident #7 is totally dependent on staff for eating. In an interview conducted on 02/22/23 at 2:00 PM, during the resident council meeting, residents stated that there is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide fortified foods for three residents during meal observation (Resident #7, Resident #1, and Resident #14). This has the potential to affect ten residents that are on fortified food diet orders. The findings included: A review of the Fortified Foods list provided by the facility showed that ten residents have a physician ' s order for fortified food with meals. In an observation conducted on 02/22/23 at 5:00 PM in the main kitchen, the Food Service Director/Cook was observed on the tray line plating the food on the plates and reading the meal tickets for each resident with gloves on. He was asked by Surveyor what is the fortified food for dinner, and he said it was the mashed potato and pointed to the metal container that was on the food warmer. A record review showed that Resident #7 was admitted on [DATE], and the Minimum Data Set (MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 7, which is…

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, it was determined that the facility failed to store, prepare, serve, and distribute food in accordance with professional standards for food safety that, include not keeping cold foods at the correct temperature of 41 degrees Fahrenheit and below, keeping personal items in the food production area, and practicing hand hygiene while handling food. The findings included: 1) During the initial kitchen tour on 02/20/23 at 9:27 AM, accompanied by, Dietary Manager, the following were noted: There was an accumulation of food residues on the sharpening stones of the slicer. There was a cooler containing water that had unidentified matter floating in the water. There was an accumulation of debris under the shelving in the dry storage area. The baseboard covering the floor and wall juncture by the three-compartment sink and the mechanical ware washing machine was not secured to the wall. Under the sanitizer basin of the three-compartment sink, the pipe was leaking directly onto the floor when the basin was dumped. 2) In a visit to the central…

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.