Helia Healthcare Of Newton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate direct care staffing to meet resident's needs. This has the potential to affect all 36 residents living at the facility. Findings include: On 4/2/24 at 8:40am, V1, Administrator, stated she is the staff member responsible for scheduling nursing staff. V1 stated that for each 8-hour shift, one nurse and two CNA's (Certified Nursing Assistants) are scheduled. V1 stated on Easter Sunday, 3/31/24 the facility experienced, A staffing situation. V1 stated the two CNAs and one nurse scheduled for 6am to 2pm called in sick. V1 stated she called other CNA and nursing staff and everybody refused to come in except V9, Registered Nurse/Minimum Data Set Coordinator, V1 stated V1 worked as a CNA, although she is not certified, and she and V9 had to perform all resident care from 6:00am to 2:00pm until staff came in to relieve them. V1 denied there were any negative outcomes associated with this event. On 4/3/24 at 9:55am, R4 was alert and oriented.…

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 the services of a trained, competent Certified Nursing Assistant (CNA) on 3/31/24. This has the potential to affect all 36 residents living at the facility. Findings include: On 4/2/24 at 8:40am, V1, Administrator, stated on Easter Sunday, 3/31/24 the facility experienced, A staffing situation. V1 stated the two CNAs and one nurse scheduled for 6am to 2pm called in sick. V1 stated she called other CNA and nursing staff and everybody refused to come in except V9, Registered Nurse/Minimum Data Set Coordinator. V1 stated V1 worked as a CNA, although she is not certified as a CAN. V1 stated she and V9 had to perform all resident care duties from 6:00am to 2:00pm. V1 denied there were any negative outcomes associated with this event. V1 acknowledged she performed transfers and incontinence care with no training or experience in personal care. V1 denied feeding residents or assisting with resident medications or treatments. On 4/3/24 at 9:55am, R4 was alert and oriented. R4 stated on Easter morning only V1 and V9 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 interview and record review, the facility failed to provide the services of a full time Director of Nurses/DON. This has the potential to affect all 36 residents living at the facility. Findings include: On 4/2/24 at 8:40am, V1, Administrator, stated V2, former DON, walked out 3/24/24, giving no notice of termination of employment. V1 stated V2 had stated she was tired of having to frequently work the floor as a nurse in addition to her DON duties. V1 stated there have since been no interested applicants. V1 stated the facility's other nurses, as well as corporate staff, have had to take over some of the DON duties. V1 stated V2 acted as the facility's Infection Control Preventionist and no staff has been assigned to take over those duties. V1 stated V2 is still employed by the facility as a PRN (as needed) staff nurse. On 4/11/24 at 3:30pm, V2 stated she left the position on 3/24/24 because she was tired of not being able to spend time with her family due to her DON duties as well as working the floor when there were call ins. V2 stated she is still employed by the…

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

Based on interview and record review, the facility failed to provide sufficient kitchen staff to carry out nutrition services on 3/26/24. This has the ability to affect all 36 residents living at the facility. Findings include: On 4/2/24 at 9:25am, V1, Administrator, stated the facility's long term Dietary Manager died suddenly on 2/15/24. V1 stated her replacement started on 3/28/24. V1 stated in addition to the new Dietary Manager, there are two full time cooks, one morning and one afternoon. V1 stated the kitchen is fully staffed based on their census according to their corporation's guidelines. V1 stated on 3/26/24, Tuesday, one of the cooks called in and the other cook was scheduled to come in at 11:30 and could not come in early, so V1 cooked breakfast that morning. V1 stated she prepared scrambled eggs and provided a choice of cereal as well as donuts, which she stated were not on the menu that day but that combination had been on the menu previously as a Dietician approved meal. V1 stated for lunch she ordered pizza and breadsticks and served chocolate chip cookies which had…

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 check the dish machine and surface cleaning agent for the correct proportion of a sanitizing agent, failed to maintain equipment, food contact surfaces and storage areas in a clean and sanitary manner, and failed to store foods to prevent potential contamination. This has the potential to affect all 36 residents living in the facility. Findings include: On 4/2/24 at 11:15am, all cabinets in the kitchen were noted to be covered on the outside with a layer of grime. The floors throughout the area were sticky and had dried food debris around the and under the stove and under prep tables. The steam table held food debris and grime in its empty compartments. All drawers in the kitchen contained food debris. Shelves under prep tables had a thick layer of grime and also food debris. The cooler doors were dirty and grimy with food debris in the bottom. The microwave was dirty inside and out, the turntable had what appeared to be a layer of baked on oatmeal, and there was food debris under the turntable. There was 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 observation, interview, and record review, the facility failed to serve the appropriation portions for a lunch meal according to the menu spreadsheet for four (R3, R9, R13, R14) of eight residents reviewed for nutrition in the sample of 17. Findings include: On 4/2/24 at 11:45am, lunch service trayline was observed. V4, Cook, stated regular trays were to receive a 4 ounce portion of the ham and augratin potato casserole entree. V4 used a 4 ounce scoop to portion the casserole for R3, R9, R13, and R14's trays. The Menu Spreadsheet for lunch 4/2/24 for regular texture diets called for the service of an 8 ounce ladle of the ham and potato casserole. R3's Face Sheet documented an admission Date of 8/12/23 and listed diagnoses including Atherosclerotic Heart Disease and Hypertension. R3's Physicians Orders listed an order for a regular texture diet. R9's Face Sheet documented an admission Date of 7/15/21 and listed diagnoses including Hearth Failure and Anxiety Disorder. R9's Physicians Orders listed an order for a regular diet. R13's Face Sheet documented an admission Date 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 provide twice weekly showers for 3 of 17 dependent residents (R4, R12, R13) reviewed for ADL (Activities of Daily Living) care in the sample of 17. Findings include: 1. R4's Face Sheet documented an admission Date of 5/31/17 and listed diagnoses including Anxiety Disorder, Hypertension, and Osteoarthritis. R4's Minimum Data Set (MDS) dated [DATE] documented that R4 requires substantial assistance from staff for bathing or showering. March and April 2024 Shower Sheets documented that R4 received showers on 3/2/24, 3/4/24, 4/4/24, 4/8/24, and 4/11/24, with only one shower given on the week of 3/3/24, no showers given on the weeks of 3/10/24, 3/17/24, and 3/24/24, and only one shower given on the week of 3/31/24. On 4/3/24 at 9:55am, R4 was alert and oriented. R4 stated she is to get a shower twice weekly, and she was to have gotten a shower on 4/1/24 but didn't because there was no hot water on the North Hall where she lives. R4 stated nobody offered to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to safely transfer a resident requiring the use of a mechanical lift for 1 of 4 residents (R13) reviewed for transfers in the sample of 17. Findings include: On 4/4/24 at 12:05pm, V1, Administrator, identified R13 as a resident who requires mechanical lift transfers. R13's Face Sheet documented an admission Date of 2/6/24 and listed diagnoses including Cervical Spine Fusion following Wedge Compression Fracture. R13's Minimum Data Set, dated [DATE] documented that R13 is dependent on 2 or more staff members for transfers. R13's Physical Therapy Evaluation dated 2/7/24 documented, Patient is bed bound and uses (a mechanical lift) for transfers. On 4/10/24 at 3:00pm, V13, Certified Nursing Assistant, stated at times there is only one nurse and one CNA per shift, and that V13 has had to do mechanical lift transfers on residents by herself, which she stated is not policy. V13 stated there have been no negative outcomes associated with these transfers. On…

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 nutritional supplements according to physician's orders for four (R3, R14, R15, R16) of four residents reviewed for nutrition in the sample of 17. Findings include: On 4/2/24 at 11:45am, lunch trayline was observed. Although the diet cards of R3, R14, and R16 specified they were to be served a liquid nutritional supplement, none was sent on their trays. During lunchtime dining observation on 4/3/24 at 11:25am, R3, R15, and R16 did not get supplements on their tray. R3's Face Sheet documented an admission Date of 8/12/23 and listed diagnoses including Atherosclerotic Heart Disease and Hypertension. R3's Physicians Orders listed an order for a liquid nutritional supplement at breakfast and lunch. R14's Face Sheet documented an admission Date of 1/25/20 and listed diagnoses including Alzheimer's Disease and Hypertension. R14's Physicians Orders listed an order for a liquid nutritional supplement at lunch. R15's Face Sheet documented an admission date of 3/31/22 and listed diagnoses including Huntington'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.

Based on observation, interview, and record review, the facility failed to ensure residents are free from significant medication errors for one of four residents (R7) reviewed for medication errors in the sample of 17. Findings include: R7's Face Sheet documented an admission Date of 1/27/23 and listed diagnoses including Diabetes Type 2 with Diabetic Neuropathy. R7's April 2024 Physicians Orders documented an order for Humalog U-100 Insulin per sliding scale as follows: If blood sugar is less than 60, call the Physician. If Blood Sugar is 200 to 250, give 2 Units. If Blood Sugar is 251 to 275, give 4 Units. If Blood Sugar is 276 to 300, give 6 Units. If Blood Sugar is 301 to 350, give 8 Units. If Blood Sugar is 351 to 400, give 10 Units. To be given three times daily, dose 1 from 6:00am-10:00am, dose 2 from 11:00am-2:00pm, and dose 3 from 3:00pm-6:00pm. The Physicians Orders also documented an order for Insulin Lispro give 12 units three times daily, dose 1 from 6:00am-10:00am, dose 2 from 11:00am-2:00pm, and dose 3 from 3:00pm-6:00pm On 4/4/24 at from 7:15am to 8:00am, V8,…

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 provide timely and thorough incontinence care for a dependent resident who requires assistance with toileting and hygiene for one of four residents (R1) reviewed for incontinence care in the sample of four. Findings include: R1's Face Sheet documented an admission date of 1/31/24 and listed diagnoses including Cerebral Infarction, Diabetes Type 2, and Transient Cerebral Ischemic Attacks. R1's 2/5/24 MDS (Minimum Data Set) documented a Brief Inventory for Mental Status Score of 8, indicating R1 has moderate deficits in cognitive functioning. The same MDS documented that R1 is always incontinent of both bowel and bladder and is dependent on staff for toileting and hygiene. R1's Care Plan dated 2/12/24 documented a problem area,Resident experiences bladder and bowel incontinence, with a corresponding intervention, Provide incontinence care after each incontinent episode. On 2/28/24 at 8:55am, V5, Family Member, stated R1 was admitted to the facility on…

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

Based on interview and record review, the facility failed to have a Registered Nurse (RN) for at least 8 consecutive hours, 7 days a week. This has the potential to affect all 38 residents who reside at this facility. This past non-compliance occurred between 1/14/23 and 5/20/23. Findings include: On 7/20/2023 at 2:00 pm, V6 (Regional Director of Operations) stated that for the following dates in January 2023 (1/14/23 and 1/28/23), February 2023 (2/25/23), and May 2023 (5/20/23) there was no Registered Nurse (RN) coverage for those days. On 7/20/23 at 2:15 pm, V1 (Administrator) stated that the nursing agency RN's had picked up these shifts to cover the hours and then did not show up for the actual shift. The facility at this time did not have many RN's on staff and many were working on finishing their schooling. As of July 1, 2023 the facility has only RN's on staff with the exception of a new hire (Licensed Practical Nurse) as of 7/20/23. A facility document titled Resident Census and Condition dated 7/20/23 documents there are currently 38 residents living in the facility. Prior…

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 correctly code restraint use for 1 (R11) of 2 residents reviewed for Minimum Data Set (MDS) restraint coding in the sample of 21. Findings Include: Review of R11's Minimum Data Set, dated [DATE] and documented as being a quarterly review assessment noted in section P0100 Physical Restraints, A. Bed Rail is documented as 1. Used less than daily. On 07/19/23 at 01:58 PM, R11 was observed lying in bed sleeping. No bed rails or other restraint devices of any kind were observed being utilized or in place on her bed. Review of R11's current and active Physician Orders documents no order for a bed rail or any other restraint use. On 07/20/23 at 11:24 AM, V4 (MDS / Care Plan Coordinator) acknowledges that R11's 6/20/23 MDS did have an error in coding, and R11 does not utilize a bed rail as a restraint. V4 stated she will get the coding error corrected.

Based on interview and record review the facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASARR) for 1 of 2 residents (R22) reviewed for PASARR's in the sample of 21. Findings Include: R22's PASARR, as provided by the facility, dated 11/1/19 documents no Developmental Disability or Mental Illness diagnoses during this evaluation, therefore not requiring a level II screening. Review of R22's Continuity of Care with a created date of July 20, 2023 documents active diagnosis of Delusional Disorders with an effective date of 05/27/2022. This same document also lists a diagnosis of Major depressive disorder, single episode, moderate with an effective date of 06/23/2023. No PASARR re-evaluation is documented as being completed after these diagnoses were added. On 07/20/23 at 09:28 AM, V5 (Social Services) stated that residents only receive a PASARR screening when they are admitted to the facility, and are not referred back for re-evaluation should new diagnoses be added. V5 confirms that R22 was not referred back for a PASARR Level II…

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, observation, and record review, the facility failed to provide the required supervision to prevent a fall for 1 of 7 residents (R31) reviewed for falls in the sample of 21. Findings include: On 7/28/23 at 12:45pm, R31 was observed in the dining room during lunch service. R31 was in a specialty high backed wheelchair, and was being fed by staff. R31 was noted to be contracted in all limbs and was very spastic, making frequent involuntary jerking movements. R31's Face Sheet listed an admission Date of 3/31/22, and diagnoses including Huntington's Disease and Dysphagia. R31's Fall Risk assessment dated [DATE] documented that R31 is at high risk for falls. R31's Minimum Data Sets dated 1/6/23, 4/5/23, and 6/15/23 all documented that R31 requires extensive assistance from at least 2 staff for transfers, locomotion on the unit, and personal hygiene, and is totally dependent on two plus staff for bathing. R31's Care Plan with a start date of 7/11/22 and the most recent review date of 7/19/23…

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 a residents medication regimen was free from unnecessary medications for one resident of five residents (R4) reviewed for unnecessary medications in the sample of 21. Findings include: R4's Face Sheet documented an admission date of 2/1/23, a date of birth indicating R4 is [AGE] years of age, and diagnoses including Hypertension, Diabetes Type 2 and Developmental Disorder of Scholastic Skills, unspecified. R4's Behavior Tracking for May, June, and July 2023 documented that R4 has displayed no behaviors in that time. R4's July 2023 Physician Order Sheet documented an order for Zoloft 50 mg (milligrams) one tablet daily, Seroquel 25mg one tablet every morning, and Seroquel 50mg one tablet at bedtime, all with a start date of 2/1/23. R4's AIMS (Abnormal Involuntary Movement Scale) dated 5/10/23 documented that R4 is not experiencing any side effects from atypical antipsychotic use. R4's Psychiatric Initial Diagnostic Interview dated 2/16/23…

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 dishes in the dishwasher were being properly sanitized. This has the potential to affect all 37 residents residing in the facility. Findings include: On 08/15/22 at 10:55 AM, V19 (Cook) stated she did not know how to check the sanitizer in the dish machine. V19 asked V8 (Dietary Manager) how to test the sanitizer and V8 handed her the quaternary ammonia test strips and told her how to test it. After three attempts of trying to test it, V19 was asked what kind of sanitizer the machine used and what kind of test strip she was using. V19 (Cook) read the label stating sodium hypochlorite and realized the test strips and sanitizer where not compatible. After finding the correct strips, tested the sanitizer in the machine and it read 20 parts per million (PPM) Chlorine. On 08/15/22 at 10:58 AM, V8 (Dietary Manager) stated she checked the machine this morning and it read 100 ppm Chlorine. On 08/15/22 at 11:40 AM, V20 (Cook) started doing dishes again and when asked to check the sanitizer in the dish machine,…

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, observation and record review, the facility failed to utilize Personal Protective Equipment (PPE) in accordance with professional standards of practice and failed to utilize and/or correctly apply approved disinfectants to prevent the spread of Covid-19. This has the potential to affect all 37 residents that reside at the facility. Findings Include: On [DATE] at 9:00 AM, V2 (Director of Nursing) provided the Facility document titled, Daily Census Report: [DATE] this document was marked with the Covid-19 residents and date of positivity by V2. This list documented that R2, R16 and R32 were positive for Covid-19. On [DATE] at 11:35 AM, V7 (Minimum Data Set Coordinator/Care Plan Coordinator) was assisting delivering residents lunch trays with her N95 respirator on. The bottom strap of the N95 mask was not worn properly, as the bottom strap was hanging down in front of her mask. On [DATE] 11:46 AM, V7 (Minimum Data Set Coordinator/Care Plan Coordinator) was still wearing her N95 mask improperly…

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, record review and interview, the facility failed to provide a safe, functional and sanitary environment for the folding and storage of clean clothes. This has the potential to affect all 37 residents residing at the facility. Findings Include: On 08/18/22 at 2:15 PM during inspection of the laundry facility, the room was noted to be rectangular with the washers and dryers on the opposite wall from the entrance. There were clean clothes noted across from the washers and dryers, as well as on the wall next to the entrance. Directly above the washers was a 6 foot by 6 foot hole in the drywall ceiling. Insulation was observed hanging down from the hole. There was visible mold on the insulation. There were dust and drywall particles falling onto the floor from the ceiling. Above the entrance there was another 3 foot by 4 foot hole in the ceiling with insulation and mold hanging down. There was a lot of airflow from the air conditioner vents blowing the drywall particles and insulation around the room. The residents clothes were exposed to these dust particles,…

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 provide food at palatable, hot temperatures for 4 (R15, R29, R31 and R3) of 4 residents reviewed for cold food in a sample of 37. Findings include: On 08/16/22 at 9:30 PM - 10:30 AM, during resident council meeting R15, R29, R31 and R3, all alert and orientated, stated, the food is cold, especially at breakfast. The Summer 2022 Regular Week 2 menu for 08/16/22 documents: Teriyaki Chicken, white rice, sugar snap peas, wheat bread, peanut butter brownies and margarine. On 08/16/22 at 11:00 AM, the surveyor's metal stemmed digital thermometer was calibrated using the ice point method. On 08/16/22 at 1:05 PM, a test tray was received off of the hall cart and was temped with the metal stemmed thermometer. The chicken was 98.0 degrees Fahrenheit, the rice was 98.1 degrees Fahrenheit, and the peas were 100.1 degrees Fahrenheit. All items on the plate tasted cold.

Based on observation, interview and record review the facility failed to ensure residents were offered snacks and that snacks were distributed per the facility policy for 4 (R15, R29, R31 and R3) of 4 residents reviewed for providing snacks in a sample of 37. Findings include: On 08/15/22 at 9:30 AM, the snack cart was observed behind the nurse's station with an uncovered pitcher of water, an uncovered pitcher of tea, an undated plate of cut up sandwiches and some small bowls of grapes. On 08/15/22 at approximately 3:00 PM the snack cart was taken back to the kitchen without ever leaving the nurse's station. All food items still appeared to be present on the cart except for half a sandwich, which R18 came to the nurse's station and asked for at 2:15 PM. On 08/16/22 at 9:30 AM, the snack cart was observed behind the nurse's station with an uncovered pitcher of water, an uncovered pitcher of tea, an undated plate of cut up sandwiches and some small bowls of cake. On 08/16/22 at approximately 3:00 PM, the snack cart was taken back to the kitchen without ever leaving the nurse's station…

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

Based on observation, interview and record review, the facility failed to follow the physician ordered diet for three (R1, R15 and R34) of 12 residents in a sample of 27. Findings Include: The facility diet spreadsheet dated, Cycle Day: 9, Monday 06/06/2022 documents: Regular diet: oven baked fish 1 fillet, parsley noodles 4 ounces, tossed salad 1 cup, breadstick 1 each and strawberry ice cream 1 each. Mechanical soft diet: ground oven fish #6 (4.75 ounces) scoop with 2 ounces gravy, parsley noodles 4 ounces, shredded lettuce 1 cup, breadstick 1 each, strawberry ice cream. The Pureed diet: Pureed fish #8 scoop, pureed parsley noodles #8 scoop (0.5 cup), pureed green beans #16 scoop (2 ounces), pureed bread 2/3 slice and vanilla pudding #8 scoop. On 08/15/22, in reference to the menu above dated 06/06/22, V8 (Dietary Manager) stated that it is the correct menu, it is on the next cycle of the menu, that is why the date is not correct, it has not been updated. The recipe #681 documents: fish oven baked ground: 2. Remove amount of cooked fish and place in a food processor. Grind 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.