Hope Creek Nursing & Rehab

Based on record review and interview the facility failed to effectively resolve grievances voiced in resident council meetings. This failure has the potential to affect all 160 residents who reside in the facility. Findings Include: Resident Council Meeting Minutes dated 10/25/23 documents concerns from residents stating the kitchen needs to be more organized to be able to serve meals on time, and there needs to be more staff in the dining room to help serve meals on time as well. The General Feedback/Grievance Form dated 10/25/23 documents Resident Council topic of concern Dietary. Detailed Description of Occurrence: kitchen to be more organized, need service to be faster, would like alternatives to spicy food. The Steps taken to investigate concern and corrective action taken areas were blank. The Resident Council Meeting Minutes dated 11/29/23 documents concerns from residents that their meal tickets that staff helps them fill out does not always match what they are serving for the meal, prefer their milk in the cartons, soups are not hot enough and council members are wondering…

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 store dry foods in a clean manner and failed to ensure all kitchen staff had their hair covered. These failures have the potential to affect all 160 residents who currently reside in the facility. Findings Include: The facility's Employee Health and Personal Hygiene policy dated 4/2017 documents Food service employees shall maintain good personal hygiene and free from communicable illnesses and infections while working in the facility. Hair restrains will be worn at all times. Beards should be well trimmed and covered with an appropriate hair restraint. The facility's Storage of dry foods/supplies policy dated 4/2017 documents dry foods stored in bins such as flour and sugar will be removed from the original packaging. Storage bins used will be kept clean, labeled and dated. Scoops will not be stored in the food bins. On 8/27/24 at 9:00 AM in the dry storage room in the kitchen there were four clear bins individually marked oatmeal, flour, thickener and bread crumbs. None of the bins were labeled with dates.…

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 don PPE (Personal Protective Equipment) properly during a COVID-19 outbreak, ensure Personal Protective Equipment (PPE) was utilized throughout wound care, residents were placed in contact isolation with active wound infections and Enhanced Barrier Precautions per order, assess residents for signs and symptoms of COVID-19, initiate isolation precautions and ensure a resident's environment was kept free from cross contamination of MRSA (Methicillin- Resistant Staphylococcus Aureus) pathogen during wound care for eight of 32 residents (R55, R37, R57, R71, R101, R114, R122, R127) reviewed for Infection Control in the sample of 124 residents. These failures have the potential to affect all 160 residents who currently reside in the facility. Findings Include: 1.The Facility's Post Public Health Emergency-Standard and Guidelines policy dated 5/16/2023 documents The facility will follow CDC (Center for Disease Control) guidelines including prompt detection, triage and isolation of potentially infectious residents to…

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

Based on observation, interview and record review, the facility failed to provide an ongoing program of activities daily to meet the resident's physical, mental, and psychosocial well-being. These failures have the potential to affect all 35 residents residing in building four on the second floor. Findings include: The facility roster, dated 8/26/24, documents 35 residents (R5, R11, R16, R20, R26, R28, R29, R33, R34, R39, R41, R46, R49, R51, R54, R57, R65, R71, R72, R75, R78, R83, R86, R90, R96, R101, R106, R109, R110, R114, R125, R126, R129, R135, R141) reside on building four on the second floor. The Quality of Life Policy and Procedure, no date, documents III. Activities A. The Facility shall provide, based on the comprehensive assessment and careplan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both…

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

Based on observation and interview, the facility failed to ensure staff treated the resident with dignity and respect for one resident (R101) reviewed for resident's rights in a sample of 124. Findings include: On 08/26/24 at 10:00 AM, R101 stated she had diarrhea during the night, and no one answered R101's call light. R101 stated she had to clean herself up but made a mess on the bed and pointed at the blanket on the bed. R101 stated the staff were notified the blanket needed to be washed. On 8/26/24 at 10:00 AM, R101's bedside table was observed with a breakfast tray and a blanket on the bed was observed with a brown/diarrhea stool smear approximately 5 centimeters by 12 inches long. Multiple spots of brown/diarrhea stool were observed next to R101's bed on the floor. On 8/26/24 at 12:30 PM, R101 was observed to be lying in bed with a lunch tray on the bedside table (breakfast tray had been removed), fully clothed, covered with a blanket reading a book lying on the soiled blanket and brown spots remained on the floor. On 8/26/23 at 2:48 PM, R101 was observed in bed (lunch tray…

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 implement their abuse prevention program to protect residents from abuse for three (R84, R103, and R500) of four residents reviewed for abuse in the sample of 124. Findings include: The facility's Abuse Prevention Program, revised 3/1/21, documents Employees are required to immediately report any incident, allegation, or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or a crime against a resident they observe, hear about, or suspect to the Administrator. In the absence of the Administrator, reporting can be made to the DON (Director of Nursing). Upon learning of the report, the Administrator or in the absence of the Administrator, the DON shall initiate an incident investigation. All incidents, allegations or suspicion of abuse, neglect, exploitation, misappropriation of property, or a crime against a resident will be documented. Any incident or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or a crime against…

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 identify and investigate a potential allegation of verbal and physical abuse for two (R84 and R500) of four residents reviewed for abuse in the sample of 124. Findings include: The facility's Abuse Prevention Program, revised 3/1/21, documents: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The following Procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party. Upon receiving reports of physical or sexual abuse, the Charge Nurse will immediately examine the resident. Findings of the examination must be recorded in a separate Incident Report and the resident's medical record. This report shall be made immediately, but no later than two hours after the allegation is made. The Charge Nurse must complete an incident report and endeavor to obtain a…

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

Based on interview and record review the facility failed to do a Level 2 PASARR (Pre- admission Screening and Resident Review) screen for one of two residents (R73) reviewed for PASARRs in total sample of 124. Findings Include: The facility policy, named, Resident Assessment Policy and Procedure, dated 2019, documents the following: The facility shall coordinate assessments with the preadmission screening and resident review (PASARR) program. Referring all Level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. The facility shall notify the state mental health authority or State intellectual disability, as applicable, promptly after a significant change in the mental or physical condition of a resident who has a mental disorder or intellectual disability for resident review. R73 's Medical Diagnosis List, dated 2/10/2021, documents the following diagnosis: Alcoholism, Anxiety, Depression, Disorganized Schizophrenia, 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 record review and interview the facility failed to update the care plan to reflect the removal of the tracheostomy for one of one resident (R127) reviewed for careplans in a sample of 124. Findings include: The facility policy, named Comprehensive Person-Centered Care Planning Policy and Procedure, dated 2022, documents the following: The facility will develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care. The interdisciplinary team will review and revise after each assessment both the comprehensive and quarterly review assessment. R127's Physician Order Sheets, dated 8/20/2024, documents the following: Mid neck: Cleanse. with wound cleanser, apply an antibiotic ointment and cover with band-aide as needed for discontinued trach site. R127's Care Plan dated 6/26/2024, documents the following: R127 has a tracheostomy related to impaired breathing mechanics. R127's Care Plan has not been revised to show the removal of the tracheostomy. On 8/29/2024 at 10AM V19/MDS (Minimum Data Set/Care plan…

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 provide range of motion programming to residents with limitations in range of motion for two of seven residents (R57, R78) reviewed for limited range of motion in a sample of 124 residents. Findings include: 1. R57's current care plan documents I would benefit from participation in an AROM (Active Range of Motion) Restorative Nursing Program as evidenced by the following risk factors and potential contributing diagnosis: History of Cerebral Vascular Accident (lack of blood flow to the brain) with Hemiplegia or Hemiparesis both involve weakness or paralysis on one side of the body). Resident will have AROM exercises to the following extremities- left upper extremity, left lower extremity, right upper extremity, right lower extremity. Interventions: The Restorative Aide and/or Unit Aide will complete AROM Programming to the following extremities bilateral upper and lower 15 repetitions times two sets six to seven days per week. R57's Point of Care History Restorative Nursing Active Range of Motion flowsheet lacked…

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

Based on observation, interview and record review, the facility failed to ensure a residents indwelling urinary catheter drainage bag was secured in a dignity enclosure bag for one of four residents (R55) reviewed for urinary catheters in the total sample of 124. Findings include: Facility's (indwelling urinary catheter) Foley Catheter Management Policy, dated 2/28/19, documents, Policy: the facility will have a system for the management of urinary catheters. All Catheter bags are covered with privacy bags at all times. R55's Care Plan, dated 7/8/24, and 8/27/24 states R55 has 16fr, Balloon 10ml indwelling catheter due to hydronephrosis. On 8/28/24 at 10:47 AM, R55 was sitting in a wheelchair in her room. R55's indwelling urinary catheter drainage bag was attached to the underneath of her wheelchair touching the ground. The drainage was not contained in a privacy covering. On 8/29/24 at 9:56 AM, V2 (DON, Director of Nursing), confirmed that all residents who have an indwelling urinary catheter should have a privacy bag covering the urinary drainage bag and it should be kept off of…

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

Based on observation, interview and record review the facility failed to store medications in a safe manner for three residents (R7, R5, and R124) observed during a routine medication pass in a total sample of 124. Findings Include: The facility's Storage of Medications policy dated 5/8/19 documents the purpose of the policy is to ensure that medications are stored in a safe, secure and orderly manner. Medications are stored in the containers in which they are received. On 8/27/24 at 8:10 AM V22 (Registered Nurse) opened her medication cart and pulled out a clear medicine cup full of pills with writing on the side and administered the medications to R124. V22 stated that the medicine cup was full of R124's morning medications to include: Aspirin 81 mg (milligrams), Clopidogrel 75 mg, Lisinopril 5 mg, Oxybutin 10 mg, Vitamin D 10 mg, Keflex 500 mg, Carbidopa-Levodopa 25-100mg, Ropinorole .25 mg and Triheyphenidyl hydrochloride 2 mg. Also, on 8/27/24 at 8:10 AM V22 stated that she did not normally prepare medications before she is ready to administer them. V22 stated that there 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.

Based on observation, interview, and record review, the facility failed to ensure coordinated care was implemented by failing to ensure documented hospice services rendered was included in the resident's medical record and available and accessible to the interdisciplinary team (IDT) for one of 11 residents (R71) reviewed for Hospice care Management in a total sample of 124. Findings include: The Nursing Facility Hospice, General Inpatient and Respite Care Services Agreement, dated 10/19/20, documents Hospice will develop a Plan of Care which will identify the care and services that are needed and will specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Plan of Care. The Plan of Care will also reflect the participation of the Hospice, the facility, and the Hospice patient and his or her family to the extent possible. A copy of the Plan of Care will be furnished to the facility upon each update. Hospice will provide representatives of the Facility with access to attend and participate in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent resident to resident physical abuse for one resident (R2) of three residents reviewed for abuse in the sample of four. Findings include: Facility Policy/Abuse Prevention Program dated 3/1/21 documents: It is the policy of this facility to prohibit and prevent abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers or staff of other agencies, family members, legal guardians, or other individuals. Abuse (definition): The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including caretaker, of goods and services that are necessary to attain or maintain physical, mental,…

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 ensure medications were administered within the one hour before/one hour after the designated 8:00 a.m. and 9:00 a.m., medication pass for two residents (R4 and R6) of four residents (R2, R3, R4, and R6) reviewed for medications being administered on time, in a total sample of four. FINDINGS INCLUDE: Facility policy, entitled Medication Administration, not dated, document, Unless otherwise specified by the physician, medications will be administered within 60 minutes before or after the facility's dosing schedule, except before or after meal orders and non-routine time ordered medications and 4. Medication Administration Record will be signed after for each medication administered to the resident. Medications that are refused by the resident or are not administered for other reasons will be circled on the particular day of no administration. The reason for not administering the medication will be documented on the back of the Medication Administration Record. On 10/12/23, V2 Confirmed, according to the time-stamped…

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 store food off the floor in the dry food storage area, refrigerator, and freezer. This failure has the potential to affect 123 of the 125 residents residing in the facility. Findings include: The facility's Food Storage of Dry Foods/Supplies policy dated 4/2017 documents Food and hoods shall be stored at minimum of six inches off the floor and 18 inches from the ceiling and clear of ceiling sprinklers, sewer pipes and vents. The facility's Storage of Refrigerated/Frozen Foods policy dated 4/2017 documents Foods should be stored at a minimum of six inches from the floor. On 8/20/23 at 6:26 AM, a walk-through of the kitchen and food storage areas was conducted with V4, Human Resources Director (HR). During the walk through, there are 24 boxes of food in the dry storage, 22 boxes of food in the freezer and 6 boxes of food in the refrigerator observed sitting on the floor. V4, HR, stated That's the food that was delivered on Friday. They just haven't gotten around to putting it away yet. On 8/21/23 at 10:40 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.

Based on observation, interview and record review, the facility failed to answer resident call lights in a timely manner for six residents (R15, R36, R38, R42, R49, R62) of 32 residents reviewed for call lights in a sample of 32. Findings include: The facility's Call Light Policy undated, documents It is the policy of the facility to have a system in place to allow staff to respond promptly to a resident's call for assistance and to ensure that the call system is in proper working order. 2) Call lights are to be answered promptly by staff who see that the call light has been activated. 1. R42's minimum data set (MDS) documents a BIMS (Brief Interview of Mental Status) of 15. A BIMS of 15 indicates an individual is cognitively intact. On 08/20/23 at 8:14 AM upon entry of R42's room, there was a strong bowel movement (BM) like odor in the room. R42 stated It's about time your here! I've been pushing my call light since 7:00AM. I had a BM and need changed. This surveyor explained the purpose of the visit. At that point, R42 picked up her call light and hit the button stating I'm…

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 Resident Council Members complaints and concerns were addressed and residents received responses and/or rationales for their recommendations for five (R15, R36, R38, R49, and R62) of five residents reviewed for Resident Council Concerns in the sample of 32. Findings include: The facility's Resident Council Policy, dated 2/9/16, documents The role of the Resident Council is to improve the quality of life of the residents who reside in the facility and to take part in actions to maintain a positive living environment. The Resident Council offers an avenue by which residents can have an active role in influencing decisions which will affect them. Participation and involvement in the Resident Council gives the resident a sense of being in control which results in a positive impact on their physical and mental health. Some objectives of the council are as follows: A. Improves communication between staff and residents; B. Serves as a source for new ideas; C. Helps to identify quality of life issues; D. Assists individual…

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

Based on observation, interview and record review the facility failed to provide an appropriate indication for use of antipsychotic medications, failed to identify target behaviors on the psychotropic medication consent, failed to document justification for administration of antipsychotic injections and failed to justify duplicate antipsychotic medications for six residents (R61, R63, R71, R73, R115, R233) of seven residents reviewed for unnecessary medications in the sample of 32. Findings include: Facility Policy/Psychotropic Drug Usage (undated) documents: Each resident receiving an antipsychotic medication for organic brain disorders (referred to as Dementia) is observed for: Episodes of the behavioral symptoms being treated and/or manifestation of the disordered thought process. The following specific conditions are acceptable to warrant the use of antipsychotic medications: Organic mental syndromes (including all forms of dementia) with associated psychotic and/or agitated behavior which are: persistent, not caused by a preventable reason and causing the resident to represent…

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 Residents were offered snacks in the evening for five (R15, R36, R38, R49, and R62) of five residents reviewed for Resident Council Meetings in the sample of 32. Findings include: The facility Snacks policy and procedure, dated 4/2023, documents Snacks will be passed out by staff during specific times as ordered by physician/RD (Registered Dietician) and in the evening time snacks will be available for residents. Procedure: Snacks will be available in the evening to provide residents with additional foods at night between dinner and breakfast meals; The snack will be provided according to what is ordered for each specific resident and passed out to the resident. On 8/20/23 through 8/22/23 between 9:00 am through 3:00 pm, there were no visible snacks for residents at the Nurses Station or dining room areas. On 8/22/23 at 9:30 AM, during the Resident Group Meeting, R15, R36, R38, R49, and R62) stated they are not offered snacks in the evening before bed and have bought their own. R36 and R62 stated 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 develop a plan of care for a resident who is a current smoker in the facility for one of one resident (R49) reviewed for smoking in the sample of 32. Findings include: The facility's Policy and Procedure of Comprehensive Care Plans revised December 2017 states, Comprehensive Care Plan will be developed for each resident that includes: problem/need of resident; measurable objectives and interventions to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the Comprehensive Assessment. This same policy documents Comprehensive Care Plans are to be done with every new admission, annually, quarterly and upon a significant change in status. The facility's Smoking Policy (undated) documents the resident's Care Plan will be reflective of the resident's needs for safe smoking. This same policy states, The Smoking Assessment will be done by the Social Services Designee with input from the IDT…

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 address a residents need for incontinence care for one resident (R42) and failed to provide daily grooming needs for one resident (R90) out of three residents reviewed for activities of daily living in a sample of 32. Findings include: The facility's Activities of Daily Living (ADL) policy undated, documents Residents are given routine daily care and HS (bedtime) care by a CNA (Certified Nursing Assistant) or a Nurse to promote hygiene, provide comfort, and provide a homelike environment . ADL care of the residents includes: Assisting the resident in personal care such as bathing, showering, dressing, eating, hair care, oral care, appropriate skin care (as indicated and as per care plan) as well as encouraging participation in physical, social and recreational activities. The facility's Incontinence Care policy undated documents It's the policy of the facility to ensure that residents receive as much assistance as needed for cleaning the perineum and buttocks after an incontinent episode or with routine daily…

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 follow a physician's order to obtain daily weights for one of 26 residents (R111) reviewed for physicians' orders in the sample of 32. Findings include: The facility's Physicians Orders (Following Physician Orders) Policy, undated states, It is the policy of this facility to follow the orders of the physician. At the time of admission the facility must have physician orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission. R111's current Order Summary Report documents R111 with diagnoses to include but not limited to: Chronic Diastolic Congestive Heart Failure/CHF; Localized Edema; and Atrial Fibrillation. This same Order Summary Report documents an order for daily weights to be obtained and a weight gain of three pounds in one day or five pounds in one week is to be reported to R111's Cardiologist (V10). This order has a start date of 7/3/23 with no end date. R111's current Care Plan…

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 to ensure a resident (R49) was not in possession of their own smoking materials (cigarettes and lighter) and failed to identify the root cause of falls (R71) for two of eight residents reviewed for accidents and supervision in the sample of 32. Findings include: 1. The facility's Smoking Policy, undated, documents All residents' smoking materials will be kept by the facility in a secure location. This same policy states, Procedure: 10. Smoking materials will be kept in a safe/secure location within the facility under staff control. 11. Residents will have no smoking materials in their possession. This includes lighters, matches, loose tobacco, rolling papers, chewing tobacco, pipes and loose pipe tobacco. A. Smoking materials may be accepted by the Administrator, SSD/Social Service Director, Charge Nurse. B. All smoking materials will be held in the facility smoking cart/receptacle (secured). R49's Quarterly Minimum Data Set/MDS assessment dated…

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 required staff to care for dependent residents. This failure has the potential to affect all 136 residents residing in the facility. Findings include: The facility's Staffing policy, no date available, documents, It is the policy of this facility to provide an adequate number of staff to successfully implement resident functions to meet resident needs. Adequate staffing ratios, by numbers and positions, required to meet the needs of the resident will be maintained. The facility's Grievance form, dated 1/6/22, documents, Topic of Concern: Call light response time. The facility's Grievance form, dated 1/20/22, documents a concern with long call light times and staff responsiveness. The facility's Resident Council/Food Committee Minutes, dated 4/27/22, document, Topic: Council members feel at times that call lights are not answered in a timely fashion. The facility's Resident Council/Food Committee Minutes, dated 5/26/22, document, Topic: Council members commented that they don't feel there is enough…

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 conduct the required 12 hours of CNA (Certified Nursing Assistant) in-services including Dementia training. This failure has the potential to affect all 136 residents residing in the facility. Findings include: The facility's CNA In-Service forms were reviewed. There was no documentation of the required CNA in-services totaling 12 hours. On 06/30/22 at 11:28 AM, V1 (Administrator) stated, There is no tracking of the individual required 12 hour CNAs trainings that the staff have received. I don't feel that we have the required 12 hours, and we are deficient. The Centers for Medicare and Medicaid (CMS) Resident's Census and Condition of Residents Report, form 672, dated and signed by V4 (Consultant) on 6/28/22, documents that at the time of the survey 136 residents resided in the facility.

Based on interview and record review, the facility failed to employ the services of a Certified Dietary Manager. This failure has the potential to affect all 136 residents currently residing in the facility. Findings Include: The facility's Classification Description for Director of Food Services job description (undated) documents the following: Duties: Develops nutrition care plans on each resident; Attends multi-disciplinary care plans as scheduled; Assumes in-service training for dietary employees. The training should encompass regular and therapeutic diets, interpretation of classification description and work procedures, use of equipment, safety and sanitation standards, and personal grooming; Follow up on nutrition goals set for residents, including supplements, diet changes, weight recommendations, etc. Evaluate progress being made towards goals with Dietician; Prepares all schedules; Writes general and therapeutic menus with approval of consultant Dietician on aspects of Food Service Department; Analyzes cost of nutrition programs; Sets budget guidelines for Food Services;…

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 residents were served warm, palatable meals. This failure has the potential to affect all 136 residents in the facility. Findings include: The facility Assessment, dated 5/27/22, documents, Services and Care We Offer Based on our Residents' Needs: Nutrition-Individualized dietary requirements, liberal diets, specialized diets, IV nutrition, tube feeding, cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions. The facility's Dining Experience policy, no date available, documents, Meals will be nourishing, attractive, palatable, and will have taken into account religious, cultural, and ethnic needs. The facility's Monitoring Food Temperatures for Meal Service policy, no date available, documents, Food temperatures will be monitored daily to prevent food borne illness and to ensure foods are served at palatable temperatures. The facility's Resident Council/Food Committee Minutes, dated 4/28/21, document, Topic: Council members concerned that at times the food is not very…

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 substitutes of equal nutritional value during meals. This had the potential to affect all 136 residents residing in the facility. Findings include: The facility's Dining Experience policy, no date available, documents, Meals will be nourishing, attractive, palatable, and will have taken into account religious, cultural, and ethnic needs. Staff will offer alternatives, food replacements or other choices if a resident is observed to not eat well, or express dissatisfaction with the meal. The facility's Menu Substitutes policy, dated 2014, documents, The facility will need to have substitutes available. Substitutes should be of similar nutritive value as the menu. This means that the substitute food to be offered should be from the same food group as the menu item that was not eaten. On 06/27/22 at 11:14 AM, R118 was alert and oriented sitting up in her wheelchair. R118 stated, The food here is horrible and it's always cold. I don't get an option of what I do and don't want before the meal is served. I…

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

Based on interview, observation and record review, the facility failed to ensure items in the kitchen were clean and dry, food items were dated upon opening, scoops were stored out of direct contact with food, beverages and nutritional supplements were not expired, and pipelines in the freezer were undamaged and functioning without signs of water damage. This failure has to potential to affect all 136 residents currently residing in the facility. Findings include: The facility's Storing Utensils, Tableware, and Equipment policy (undated) documents the following: Glasses and cups should be stored upside down/inverted. Store all scoops used for bulk foods in a clean, sanitized location. Do not store scoops for bulk food in bins. The facility's Labeling and Dating of Foods policy (undated) documents the following: Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. On 06/27/22 from 10:40 AM - 11:15 AM, a tour of kitchen was conducted with V8 (Acting Dietary…

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

Based on interview and record review, the facility's Quality Assurance Committee failed to meet quarterly to identify, review and correct identified issues. This failure has the potential to affect all 136 residents residing in the facility. Findings Include: On 6/30/2022, V1/Administrator provided the following: (The facility) Quarterly QAA (Quality Assurance Attendance) meeting dated May 27, 2022. On 06/30/2022 at 9:15 A.M., V1/Administrator, was unable to provide attendance sign-in sheets for any Quality Assurance Meetings held with documentation of who attends, or issues that have been identified and are being discussed for performance improvement, prior to 5/27/2022. At that time, V1 stated he has only conducted one QA Meeting and has no idea what happened prior to him beginning employment at the facility. The Centers for Medicare and Medicaid (CMS) Resident's Census and Condition of Residents Report, form 672, dated and signed by V4 (Consultant) on 6/28/22, documents that at the time of the survey 136 residents resided in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Noncompliance resulted in two deficient practices. A. Based on observation, interview and record review, the facility failed to complete required COVID-19 testing, failed to ensure staff donned and doffed PPE (personal protective equipment) prior to entering/exiting a COVID-19 isolation/quarantine room and failed to ensure appropriate signage was posted to identify residents in COVID-19 isolation. These failures have the potential to affect all 136 residents in the facility. B. Based observation, interview and record review, the facility failed to place a urinary catheter collection bag in a clean area for one of three residents (R67) reviewed for urinary catheters in the sample of 64. 1. Findings include: Facility Policy/COVID-19 Residents and Staff Testing dated 3/31/22 documents: Testing of Staff and Residents during an outbreak Investigation: A new COVID-19 infection in any staff or nursing home-onset COVID-19 infection in a resident triggers an outbreak investigation. Upon identification of a single new…

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 functioning call system to 20 residents (R11, R29, R32, R42, R46, R65, R67, R82, R85, R86, R92, R108, R109, R110, R117, R241, R243, R244, R245, R246) of 136 residents reviewed for call light response. Findings include: Facility Policy/Call Lights (undated) documents: It is the policy of the facility to have a system in place to allow the staff to respond promptly to a resident's call for assistance and to ensure the call system is in proper working order. 1. All facility staff must be oriented to and aware of the call light system. 2. Call lights are to be answered promptly by staff who see that the call light has been activated. 3. Bedside call lights will be seen and heard over the door of the resident's room as well as at the nurses' station area. 4. In the event of a widespread call light malfunction - bells or other means of notifying the staff will be instituted. Further every 15 minute documented rounds will be initiated until the call lights are functioning. The Centers for Medicare 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, the facility failed to ensure electronic monitoring was not tampered with for one of two residents (R34) whose rooms are electronically monitored by family in a sample of 64. Findings Include: The Facility's undated Policy and Procedure: Photographing, Video Recording, Audio Recording, and Other Imaging of Residents, Visitors and Employees policy documents, 2. Photographing/Audio Recording of Residents by Residents, Family Members and/or by Visitors: The facility is not required to obtain consent from the resident, but must be notified in advance, when the resident is the subject of the photography/audio recording and such recording is performed by the resident or the resident's family members or the resident's visitors. R34's Electronic Monitoring Notification and Consent Form dated 4/1/2022 documents, the type of electronic monitoring device I am planning to install is video and audio. The form does not contain any indication of any conditions or restrictions on the monitoring. The State of Illinois Electronic Monitoring in Long…

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 allow visitation for one resident (R82) of 13 residents reviewed for visitation during a COVID-19 outbreak in the sample of 64. Findings include: Facility Policy/COVID-19 Visitation and Communal Dining/Activities dated/revised 3/11/22 documents: Facilities must allow indoor visitation at all times and for all residents as permitted under the regulations. While previously acceptable during the PHE (Public Health Emergency), facilities can no longer limit the frequency and length of visits for residents, the number of visitors, or require advance scheduling of visits. COVID-19 Positive Residents dated 6/27/22 indicated 13 residents were identified as COVID-19 positive on that date. Resident Rapid COVID Testing Log indicates R82 tested positive for COVID-19 on 6/21/22. On 6/29/22 at 9:35am R82 stated that he and his family were told visitors are not allowed in the facility during a COVID outbreak. R82 stated he has not had any visitors since he went into isolation for COVID. At that time, R82 was in a room at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain Advanced Directives for two of five residents (R108 and R241) reviewed for Code Status in the sample of 64. Findings include: Facility Policy/Advance Directives Policy and Procedure dated [DATE] documents: The following steps will be completed to promote and implement this process: Determine upon admission whether the resident/legal representative has an advanced directive and if not, determine whether the resident/legal representative wishes to formulate an advance directive. Establish mechanisms for documenting and communicating resident choices to the IDT (Interdisciplinary team). 1. Upon admission, the facility will provide written information to resident/legal representative concerning the resident's rights to make decisions regarding medical care including the right to accept/refuse medical treatment and the right to formulate advance directives. 2. Upon admission, the facility must determine if the resident executed an advance directive…

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 recognize potential abuse for two of eleven residents (R51 and R127) reviewed for abuse in a total sample of 64. Findings Include: The Facility's Abuse Prevention Program dated 3/1/21 documents It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The Facility's Abuse Prevention Program defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse is defined as Any use of oral, written, or gestured language that includes disparaging and derogatory…

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

Based on interview and record review, the facility failed to ensure that two allegations of abuse were immediately reported to the Administrator for three of 11 residents (R34, R51 and R127) reviewed for abuse in the sample of 64. Findings include: The Facility's Abuse Prevention Program dated 3/1/21 documents It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The Facility's Abuse Prevention Program defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse is defined as, Any use of oral, written, or…

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

Based on record review and interview, the facility failed to investigate two instances of potential abuse for two of 11 residents (R34 and R51) reviewed for abuse in a sample of 64. Findings Include: The Facility's Abuse Prevention Program dated 3/1/21 documents It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The Facility's Abuse Prevention Program defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse is defined as Any use of oral, written, or gestured language that includes disparaging 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 record review and interview, the facility failed to obtain orders for routine water flushes with gastric feedings and failed to have one resident (R34) assessed by a Registered Dietician. R34 was one of three residents reviewed for nutrition in a sample of 64. Findings Include: The Facility's undated Dietitian Consultant Policy and Procedure documents, A qualified, licensed Dietitian will be contracted for consulting purposes. The Dietitian Consultant Policy and Procedures documents, The dietitian will work with the facility per contract which may include but not limited to a) assess special nutritional needs of the residents. R34's admission Record documents R34 was admitted on [DATE] with a gastric tube in place and was being fed through the gastric tube three times daily. R34's Medical History and admission Orders form dated 2/7/2022 documents Diet: IsoSource 1.5 cal (Calories) two containers bolus TID (Three times daily). R34's admission Physician Order Sheet dated 2/9/22 documents IsoSource 1.5…

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 feeding port cap was secure to prevent the unintended leakage of formula, and failed to position a resident to prevent aspiration for one of two residents (R132), reviewed for tube feedings, in a sample of 64. FINDINGS INCLUDE: The facility policy, Enteral Tube, dated October 2021 directs staff, The facility assures the safe and effective administration of enteral formulas based on nursing assessment of the resident's condition and approval by the physician. R132's current Physician Order Sheet, dated June 2022 includes the following diagnoses: Parkinson's Disease, Lewy Body Dementia, TIA (Transient Ischemic Attack) and History of Gastrostomy Tube. This same document includes the following Physician Orders: 2-Cal (Calorie) 1 can (237 ml) (Milliliters) TID (Three times daily) through g-tube by gravity, for weight loss; Flush 180 ml of water before and after bolus feeding tid. R132's current Care Plan, dated 3/22/2019 includes the following Focus Area: (R132) has a G-tube in place due to history 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 interview and record review, the facility failed to obtain a physician's order for the implementation of dialysis, failed to follow physician ordered dietary restrictions, and failed to communicate the resident's condition regularly with the dialysis center, for two of two residents (R84 and R113), reviewed for dialysis, in a sample of 64. The (undated) facility policy, Communication Hemodialysis directs staff, To ensure coordination of care for residents requiring Hemodialysis in the community. All residents that are admitted to the facility with needs for Hemodialysis will have coordination of services between the facility and the Hemodialysis unit. Special consideration will be given to residents going to dialysis to coordinate therapy, medication administration and meals. A sack lunch will be provided to residents that are going to dialysis during meal times following the special dietary orders of the resident. The facility will obtain orders from the physician for the resident dialysis. 1.) R113'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 interview and record review, the facility failed to ensure the resident's menu met a resident's nutritional preferences for one of six resident (R113), reviewed for food preferences, in a sample of 64. The (undated) facility policy, Resident Likes and Dislikes/Food Preferences, directs staff, Resident's food preferences will be recorded and consistently utilized. Data including resident likes, dislikes, allergies, food preferences will be entered into the computerized tray card system. The (undated) facility policy, Dining Experience documents, Meals will be nourishing, attractive, palatable and will haven taken into account religious, cultural and ethnic needs. All residents will be visited by the Dining Services Manager within 48-72 hours to introduce them to the dining program and inquire about food preferences and eating habits. R113's current Physician Order Sheet, dated June 2022 documents that R113 was admitted to the facility on [DATE]. This same document includes R113's current diet as:…

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.