Sunny Ridge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, it was determined the facility failed to ensure that physician-ordered medications were administered as prescribed for 2 of 3 residents (Resident #1 and Resident #2) reviewed for medication administration. This failure resulted in missed doses of essential medications and created the potential for adverse outcomes, including ineffective treatment and exacerbation of medical conditions. Findings include:1. Resident #1 was readmitted to the facility on [DATE], with multiple diagnoses including bipolar disorder, depression, and migraine disorder.A review of Resident #1's medication administration record (MAR), dated 8/4/25 - 8/22/25, documented the following physician orders had not been administered and coded (9) (code 9 meaning see progress note): Cyanocobalamin solution (Vitamin B12) inject 1 milliliter (mL) intramuscular one time a day for increased immune function for 4 days into shoulder, thigh, or buttocks started 8/5/25, documented code 9 for 3 of 4…

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, residents and staff interviews, it was determined the facility failed to maintain or enhance residents' dignity during dining when residents seated at the same table were served their meals at different times. This was true for 2 of 14 residents (#94 and #96) observed in the main dining room and 1 of 7 (Resident #30) observed in the assisted dining room. This failure had the potential to cause a decrease in residents' sense of self-worth and psycho-social well-being. Findings include: 1. On 1/6/25, the following were observed in the Main Dining Room: a. Resident #7, Resident #9, and Resident #96 were seated at the same table. Resident #7 and Resident #9 were served their meal tray at 8:10 AM and 8:13 AM respectively and started eating. Resident #96 did not receive her tray until 8:29 AM (19 minutes from when the first meal was delivered to their table). b. Resident #93, Resident #94 and Resident #95 were seated at the same table. Resident #93 and Resident #95 were observed eating their meals at 8:21 AM. Resident #94 did not receive her meal tray. - at 8:50 AM,…

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, review of the Incidents and Accidents (I&As) report, residents and residents' representatives interview, staff interviews, and residents' group interviews, it was determined the facility failed to ensure there were sufficient numbers of staff available at all times to provide nursing and related services to meet the residents' needs. This was true for 3 of 41 residents (#19, #30, and #36) reviewed for staffing concerns and had the potential to affect all residents in the facility. This deficient practice created the potential for physical and psychosocial harm if residents did not receive appropriate care or received delay of care. Findings include: a. Residents and their representatives were interviewed and stated the facility did not have sufficient staff to meet their needs. - On 1/6/25 at 11:16 AM, Resident #144's representative stated, Staff is good and care for residents, but during meal times there are not enough staff to respond to immediate needs and he is waiting for help if he…

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, review of facility policies and procedure, review of Incidents and Accidents (I&As), and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 3 of 3 residents (#4, #16, and #145) reviewed for medication administration. This failure created the potential for harm if the resident's medications were not administered according to the physician's order. Findings include: The facility's Administering Medications policy, revised 2/24, documented: -The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. -Medications are administered in accordance with prescriber orders, including any required time frame. The facility's Medication and Treatment Orders policy, revised 7/16, documented: -Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart. 1. Resident #4 was admitted to the facility on [DATE], 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 observation, policy review, Food Code review, and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, clean, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 41 residents who consumed food prepared by the facility. This placed residents at risk for potential food contamination and adverse health outcomes, including food-borne illnesses. Findings include: 1. Food Receiving and Storage: The FDA Food Code Section 3-302.12 Food Storage Containers, Identified with Common Name of Food documented, Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking,…

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, policy review, and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to initiation of medications for 1 of 5 residents (Resident #144) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the reason why medication was prescribed, the expected benefits, and the risks associated with the medications. Findings include: The facility's Psychotropic Medication Use policy, dated July 2022, documented residents (and/or representatives) have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. Resident #144 was admitted to the facility on [DATE], with multiple diagnoses including stroke, hemiplegia (paralysis) affecting the right side, and bipolar disorder (a mental illness that causes extreme mood swings). 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 staff interview, it was determined the facility failed to ensure transfer notices were provided to the ombudsman. This was true for 1 of 2 residents (Resident #6) reviewed for transfers to the hospital. This deficient practice had the potential for harm if residents were not aware of or able to exercise their rights related to transfers. Findings include: The State Operations Manual, Appendix PP, revised on 8/8/24 documented, Before transfers or discharges of a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including end stage renal disease, diabetes, and congestive heart failure (a chronic progressive condition affecting…

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, policy review, and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to the residents or their representatives upon transfer to the hospital. This was true for 2 of 2 residents (#6 and #40) reviewed for transfer. This deficient practice created the potential for harm if residents were not informed of their rights to return to their former bed/room at the facility within a specified time. Findings include: The facility's Transfer or Discharge policy, dated 10/2022, documented a notice of facility Bed-Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer. 1. Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including acute cholecystitis (inflammation of the gallbladder) and diabetes. A nursing progress note, dated 9/23/24 at 8:09 PM, documented Resident #40 complained of on and off abdominal pain for the past three days. Resident #40'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 staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 12 residents (Resident #16) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The Resident Assessment Instrument (RAI), revised 10/1/24, documents if a PASARR (Preadmission Screening and Resident Review) Level II determines a resident has a serious mental illness then section A1500 of the MDS should be marked yes. Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including dementia, PTSD (post traumatic stress disorder), and major depressive disorder. Resident #16's medical record documented a PASSAR level II, dated 1/11/22 and 6/17/22, was completed. Resident #16's admission MDS assessment, section A1500, dated 1/18/22, documented Yes, Resident #16 did…

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, record review and interview, it was determined the facility failed to ensure residents' medications were administered according to professional standards. This was true for 1 of 5 residents (Resident #17) observed during medication administration. This failed practice created the potential for Resident #17 to experience low or high blood sugar if she receives an incorrect amount of insulin. Findings include: Resident #17 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and stroke. A physician's order, dated 9/16/24 documented Resident #17 was to receive 12 units of Insulin Aspart subcutaneously (under the skin) one time a day related to diabetes. On 1/8/25 at 11:51 AM, LPN #1 took the Insulin Aspart pen, replaced the needle with a new one and dialed the pen to 12 units. LPN #1 then went to Resident #17's room and injected the Insulin Aspart to Resident #17's lower abdomen. LPN #1 was not observed to prime the insulin pen before dialing the prescribed dose…

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 staff interview, it was determined the facility failed to ensure pharmacist recommendations were followed or addressed by the attending physician. This was true for 1 of 5 residents (Resident #31) whose pharmacist recommendation was reviewed. This deficient practice created the potential for Resident #31 to use unnecessary medications. Findings include: The facility's Medication Regimen Reviews (MRR) policy, reviewed 4/2024, documented the Consultant Pharmacist performs MRR for every resident in the facility receiving medication upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated. Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity. The report contains: Resident's Name, Name of Medication, The Identified Irregularity and The pharmacist recommendation. The attending physician…

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, observation, and staff interview, it was determined the facility failed to ensure infection control prevention were maintained to provide a safe and sanitary environment. This was true for 1 of 1 resident (Resident #144) observed for infection control. This failure created had the potential to impact all residents in the facility by placing them at risk of infection. Findings include: The CDC (Center for Disease Control and Prevention) website, updated 7/12/22 and accessed on 1/14/24 stated, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices regardless of MDRO (Multiple Drug Resistant Organism) colonization status. Resident #144 was admitted to the facility on [DATE] with multiple…

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 ensure influenza vaccine was administered to a resident who consented to receive the vaccine. This was true for 1 of 5 residents (Resident #39) reviewed for immunizations. This deficient practice created the potential for harm should Resident #39 acquire, transmit, or experience complications from influenza. The facility's Infection Prevention and Control Program (IPCP) policy, revised 2018, documented an IPCP was established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy stated immunization was a form of primary prevention and widespread of use of influenza vaccine in the nursing facility was strongly encouraged. Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including hypertension and osteoporosis (a condition that causes bones to gradually thin and weaken). Resident #39's Immunizations…

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 staff interview, it was determined the facility failed to ensure residents were monitored appropriately and offered non-pharmacological interventions while receiving opioid pain medications. This was true for 4 of 8 residents (# 3, #14, #17, and # 32) reviewed for pain management. This failure created the potential for residents to experience adverse reactions due to lack of appropriate monitoring or increased pain due to not offering non-pharmacological interventions. Findings include: The Centers for Disease Control and Prevention (CDC) Clinical Practice Guideline for Prescribing Opioids for Pain, dated 2022, last reviewed 6/14/23, accessed online 2/27/24, documented clinicians should maximize use of non-pharmacological and non-opioid pharmacological therapies as appropriate for the specific condition and patient and only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risk to the patient. The facility's Pain - Clinical…

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 staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained when hand hygiene was not performed for 2 of 2 residents (#10 and #14) observed for infection control. This failure created the potential for cross-contamination and infection. Findings include: 1. Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including age related cognitive decline and malnutrition. Resident #10's record included an order to cleanse her coccyx (tailbone) wound with wound cleanser, pat dry, apply skin prep to surrounding healthy tissue, then apply hydrocolloid dressing to site until resolved. On 2/20/24 at 2:05 PM, LPN #2 was observed providing wound care to Resident #10. LPN #2 remove the soiled dressing and provided incontinent care around the wound. She then proceeded to cleanse the wound without changing her soiled gloves. On 2/20/24 at 2:11 PM, LPN #2 stated she did not realize she had not changed her gloves after…

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 policy review, record review, and staff interview, it was determined the facility failed to ensure all pertinent information was provided to the receiving facility when a resident was transferred to another health care facility. This was true for 1 of 1 resident (Resident #15) reviewed for resident transfer. This deficient practice had the potential to result in adverse outcomes if residents' specific needs were not treated appropriately and in a timely manner due to lack of information provided upon transfer. Findings include: The facility's policy for Transfer or Discharge, dated October 2022, stated, Should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility: a. The basis for the transfer or discharge. b. Contact information of the practitioner responsible for the care of the resident. c. Resident representative information, including contact information. d. Advance Directive information. e. All special instructions or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans. This was true for 2 of 12 residents (#23 and #33) whose care plans were reviewed. These failures placed residents at risk of negative outcomes if services were not provided or provided incorrectly due to lack of information in their care plan. Findings include: The facility's Comprehensive Person-Centered policy, revised March 2022, documented the care plan interventions are chosen after careful consideration of the relationship between the resident's problem areas and their cause, and relevant clinical decision making. The care plan will also include interventions addressing the underlying source of the problem not just the symptoms or triggers. 1. Resident #33 was admitted to the facility on [DATE], with multiple diagnoses including cognitive communication deficit. Resident #33's care plan, revised 12/4/23, documented staff were to monitor 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on I&A review, record review, and staff interview, it was determined the facility failed to ensure residents' care plans were reviewed and revised. This was true for 1 of 12 residents (Resident #10) whose care plans were reviewed. This created the potential for harm when Resident #10's care plan was not reviewed and revised to reflect his care needs. Findings include: The facility's Care Plan policy, revised March 2022, documented the care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including age related cognitive decline and malnutrition. Resident #10's care plan, revised on 3/29/23, documented Resident #10 was a fall risk and was in a room closer to the nurses station for increased supervision. A Nutritional Assessment, dated 3/6/23, documented Resident #10's dining ability was set-up with supervision. 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 policy review, I&A review, record review, and staff interview, it was determined the facility failed to ensure adequate supervision for residents to prevent falls. This was true for 1 of 1 resident, (Resident #10), whose record was reviewed for falls. This resulted in harm to Resident #10 when he was left unsupervised to eat in his room. Findings include: The facility's Falls and Fall Risk policy, revised February 2022, documented, based on previous evaluation and current data, the licensed nurse would identify interventions related to the resident's specific risk and cause to try to prevent the resident from falling and or minimize complications. 1. Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including age-related cognitive decline and malnutrition. A quarterly MDS assessment, dated 12/8/23, documented Resident #10 had impaired lower extremeties and required maximal assistance for transfers. Resident #10's care plan, revised 3/29/23, documented Resident #10 was a fall…

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 policy review, record review, and staff interview, it was determined the facility failed to ensure residents were free of significant medication errors. This was true for 1 of 1 resident (Resident #32) whose medications were reviewed. This failure created the potential for harm to Resident #32 when she did not receive ordered medication. Findings include: The facility's Medication and Treatment Orders policy, undated, documented drugs that are required to be refilled must be reordered from the issuing pharmacy not less than 3 days prior to the last dose being administered to ensure that refills are readily available. Resident #32 was admitted to the facility 1/19/24, with multiple diagnoses including breast cancer, acute pain, and chronic pain. Resident #32 was prescribed ABHR cream (Ativan, Benadryl, Haldol, Reglan compounded into a topical cream), apply 1 millilliter to inner wrist 3 times a day for pain management. Resident #32's MAR, dated 2/1/24 through 2/21/24, documented on 2/20/24, evening shift, the medication was administered. On 2/21/24, day shift, her MAR…

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 policy review, observation, and resident and staff interview, it was determined the facility failed to ensure two residents' (#27 and #23) food preference requests were honored. This failure put residents at risk if they experienced hunger or weight loss from not having meals provided according to their needs or preferences. Findings include: The Facility's Nutritional Assessment policy, revised October 2017, documented a comprehensive assessment for each resident included usual meal and snack patterns, food portion sizes, food restrictions, allergies, cultural, or religious practices that affected food choices and food preferences, food likes, dislikes, flavors, textures, and forms. The nutritional assessment was to also include documented current nutritional risk factors for or potential risk factors with a change in condition. 1. Resident #27 was admitted to the facility on [DATE], with diagnoses including congestive heart failure, type 2 diabetes complications, and severe morbid obesity. 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.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure food items were dated and labeled and hygiene practices followed. This failure had the potential to affect 32 of 32 residents residing in the facility who consumed food prepared by the facility, and placed them at risk of adverse outcomes including food-born illnesses. Findings include: 1. The facility's Preventing Foodborne Illness policy, Revised November 2022, documented Food and Nutrition service employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Additionally, the policy stated contact between food and bare (ungloved) hands was prohibited, as well as hair nets or caps and beard restraints were to be worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens. a. On 2/20/24 at 7:48 AM, Dietary Aide #2 was observed entering the kitchen during breakfast. She walked directly over to the bread with no observation of hand hygiene being performed. She 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 observation, policy review, and staff interview, it was determined the facility failed to ensure waste was properly contained with lids or otherwise covered. This was true for 1 of 2 outside dumpsters. This created the potential for insect and pest infestation of the facilities premises. Findings include: The facility's Sanitation policy, revised November 2022, documented garbage and refuse containers were to remain in good condition to prevent leaks, and waste was properly contained in the dumpster with lids or otherwise covered. On 2/20/24 at 11:45 AM, one dumpster was observed with the lid open, and bread rolls on the ground surrounding the dumpster. On 2/23/24 at 8:30 AM, the dumpster was observed with the lid open. On 2/23/24 at 8:33 AM, the Chef confirmed the dumpster was open and it should have been closed but it was hard to keep it closed since the nursing facility kitchen shared the dumpster with the Assisted Living facility.