Adept Nursing & Rehab of Grand Island

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interviews, the facility failed to report and submit an investigation for an injury of unknown origin to the State Agency and adult protective services within the required time frames for 1 (Resident 8) of 1 sampled resident. The facility census was 58. Findings are: A record review of a facility supplied policy titled Abuse, Neglect and Exploitation and dated 01/14/2025 revealed the facility will report all alleged violations to the administrator, state agency, adult protective services and to all other required agencies within specified time frames. Immediately, but not later then 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. A record review of an admission Record revealed the facility admitted Resident 8 on 05/24/2021 with diagnoses of hemiplegia (total or partial paralysis on one side of the body…

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 Licensure Reference Number 175 NAC 12-006.09(D) Based on record review and interviews, the facility failed to accurately code the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems), for 1 (Resident 41) of 13 sampled residents. The facility census was 58. Findings are: A record review of a facility policy titled MDS 3.0 Completion revealed under the section Coding of Assessments, all disciplines shall follow the guidelines in Chapter 3 of the current Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities) for coding of each assessment. A record review of an admission Record revealed the facility admitted Resident 41 on 12/07/2023 with diagnoses of absence of left leg below the knee,…

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.

Licensure Reference Number 175 NAC 12-006.09(A)(i) Based on record review and interview the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Nebraska Level 1 Form (an initial pre-screening for mental illness and intellectual/developmental disabilities prior to admission) screening was completed prior to resident admission into the facility for 1 (Resident 9) of 1 sampled residents. The facility census was 58. Findings are: Record review of the facility policy titled Coordination with PASARR Program dated 1/14/25 revealed that the facility coordinates with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities in accordance with the State's Medicaid rules for screening. PASARR Level 1 is an initial pre-screening that is completed prior 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 Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review the facility failed to ensure bowel care services were provided for 3 residents (Residents 8, 54, and 26) of 5 sampled residents. The facility census was 58. Findings are: A. A record review of an admission Record revealed the facility admitted Resident 8 on 05/24/2021 with diagnoses of hemiplegia (total or partial paralysis on one side of the body that results from disease or injury to the motor centers of the brain) of the left side, type 2 diabetes mellitus (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production), dementia (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior), 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.

Licensure Reference Number 175 NAC 12-006.09(H)(v) Based on observation and interview the facility failed to ensure 1 (Resident 41) of 1 sampled resident maintained their range of motion (full movement potential of a joint) to promote the resident's highest practicable level of independence. The facility census was 58. Findings are: A record review of a facility policy titled Prevention of Decline in Range of Motion dated 2024 revealed residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. A record review of an admission Record revealed the facility admitted Resident 41 on 12/07/2023 with diagnoses of absence of left leg below the knee, chronic pain, and type 2 diabetes mellitus (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate…

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 Licensure Reference Number 175NAC 12-006.08(B)(i) Based on observation, record review, and interview the facility failed to ensure that the physician completed the initial post-admission visit (30 day visit) for 2 of 4 residents reviewed (Residents 38 and 25). The facility census was 58. Findings are: A. Record review of the facility policy titled Physician Visits and Physician Delegation dated 4/1/24 revealed that it is the policy of the facility to ensure that the physician takes an active role in supervising the care of residents. The physician should see the resident within 30 days of initial admission to the facility. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission. Required visits after the initial visit may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner, or clinical nurse specialist under the supervision of a physician. The section titled Authority for Non-Physician Practitioners 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.

Licensure Reference Number 175 NAC 12-006.14 Based on observation, interview, and record review; the facility failed to promptly provide and obtain dental services for 1 (Resident 41) of 4 sampled residents. The facility census was 58. Findings are: In an interview completed on 05/18/2025 at 11:50 PM with Resident 41, Resident 41 stated they had multiple broken teeth. The resident denied seeing a dentist since being admitted to the facility in 2023. The resident voiced discomfort to mouth/teeth only when chewing tough or hard items and would like to see the dentist. Resident stated they had not been asked about needing or wanting to see the dentist. In an observation completed on 05/18/2025 at 11:55 PM of Resident 41's teeth, it was observed on the lower left side of the resident's mouth, their back teeth had holes present to the top of 2 of the teeth. A record review of an admission Record revealed the facility admitted Resident 41 on 12/07/2023 with diagnoses of absence of left leg below the knee, chronic pain, and type 2 diabetes mellitus (a common form of diabetes mellitus that…

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

Licensure Reference Number 175 NAC 12-006.0911(A) Based on observation, record reviews, and interviews; the facility failed to ensure 1 resident, (Resident 52) of 1 sampled resident received diet and preferences as requested. The facility census was 58. Findings are: An observation on 05/20/2025 at 1:10 PM, Resident 52 sat in their room in front of a meal provided by the kitchen. During an interview on 05/20/2025 at 1:10 PM, Resident 52 reported wanting to go to the bank to get money to buy their own food. Resident 52 further revealed they cannot eat the food; the hot dog has pork in it. A record review of a meal ticket on 05/20/2025 for Resident 52 revealed: Diet: Renal (A renal diet is one that is low in sodium, phosphorous and protein; a diet that cuts down on the amount of waste in their blood) Texture: Regular Diet/Other: No Added Salt (NAS), No Pork or Pork by Products Fluid Restriction: 1500 Beverages: Fluid Restriction: 8 oz fruit drink Menu: Roasted Pork Loin Buttered Noodles Broccoli & Cauliflower Diced Peaches Dinner Roll/2 teaspoon (tsp) margarine Beverage Other Menu…

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.

Licensure Reference Number 175NAC 12-0006.09(H)(iii)(1) Licensure Reference Number 175NAC 12-006.09(H)(iii)(2) Based on observation, record review, and interview; the facility failed to provide care and services to prevent pressure related skin conditions and promote the healing of pressure related skin conditions for 1 resident (Resident #1) of 3 sampled residents. The facility census was 50. Review of the facility policy titled Skin Assessment and not dated revealed that a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly there after. The section labeled documentation of skin assessment stated documentation should include date and time of assessment observations, type of wound, description of wound, and if the resident refused the assessment and why. Review of the facility policy titled Pressure Injury Prevention Guidelines and dated 01/05/2024 revealed that individualized interventions will address specific factors identified including nutritional deficit and impaired…

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 Licensure Reference Number 175NAC 12-006.17B Licensure Reference Number 175NAC 12-006.17C Licensure Reference Number 175NAC 12-006.17D Licensure Reference Number 175NAC 12-006.04A2a Based on observation, interview, and record review the facility failed to ensure that staff followed requirements for wearing and discarding of Personal Protective Equipment (PPE) (specialized equipment worn by an employee for protection against infectious disease) in resident rooms for residents with Covid-19 infection and for residents requiring Enhanced Barrier Precautions (use of PPE to reduce transmission of multi-drug resistant germs that employs targeted gown and glove use during contact with a resident) to prevent the potential for Covid-19 and cross contamination. This had the potential to affect all facility residents; The facility failed to ensure a pre-employment health history screening was completed and reviewed to prevent the potential for transmissible disease for 5 of 5 sampled facility staff which had the potential…

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 Licensure Reference Number 175NAC 12-006.18B3 Based on observations and interview the facility staff failed to ensure 3 of 27 rooms were maintained in good repair and failed to maintain wallpaper and walls in good repair in 2 of 3 halls in good repair. The facility census was 37. Findings are: The following was observed during a facility environmental tour on 05/14/2025 from 2:00 PM till 2:44 PM with the Facility Administrator (FA). -room [ROOM NUMBER] square hole in ceiling exposing under layment, warped rippling paint on the wall near the hole in the ceiling and above the window in the room, yellow brown staining around the hole in the ceiling, gray black fuzzy material along the wall to ceiling trim in this area, ceiling material cracked and protruding down. Gray black fuzzy material on the inside white portion of the curtain hanging in the room over the window. Outside of room above the window a large hole in the roof soffit. -room [ROOM NUMBER] paint on wall is pealing and warped, yellow brown staining 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 Licensure Reference Number 175NAC 12-006.09C(2) Licensure Reference Number 175NAC 12-006.09C(5) Licensure Reference Number 175NAC 12-006.09C2 Based on observation, record review, and interview the facility failed to ensure the comprehensive care plan (a written plan detailing how staff are to meet the resident's needs) included interventions to meet resident needs related to urinary elimination for 1 resident (Resident 39 and failed to include a discharge plan for 1 resident (Resident 1) of 12 total sampled residents. The facility census was 37. Findings are: A. Record review of the facility policy titled Comprehensive Care Plans dated 8/1/23 revealed that it is the facility policy to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment (a required resident assessment tool used for care planning that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175NAC 12-006.09C1c Based on record review and interview the facility failed to ensure care plan meetings were completed to allow residents/resident representatives to participate in development and revision of the resident's plan of care (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for 5 of 12 sampled residents (Residents 11, 18, 14, 1, and 25). The facility census was 37. Findings are: A. Record review of the facility policy titled Care Planning-Resident Participation dated 8/1/24 revealed the facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care). The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. The facility will honor the resident's choice in individuals to be included in the care planning process.…

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.

Licensure Reference Number 175NAC 12-006.10D Based on observation, record review, and interview the facility failed to ensure 4 (Residents #19, #11, #193, and #21) of 13 residents were free of significant medication errors for. The facility census was 37. Findings are: A. Review of a facility policy titled, Insulin, which is a medication administered by injection to help regulate blood sugar levels, Pen, dated 08/01/2024 revealed item #6, Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. Item #11 section H titled Prime the insulin pen: dial 2 units by turning the dose selector clockwise. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. Section I set the insulin dose. Review of a document labeled Instructions for Use dated 07/2023 revealed, step #6 to prime your pen, turn the dose knob to select 2 units. Hold your pen with the needle pointing up tap the cartridge holder gently to collect air bubbles at the top, continue holding your pen with needle…

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.

Licensure Reference Number 175NAC 12-006.09D3(5) Based on record review, and interview the facility failed to ensure routine bowel movements for 1, (Resident #19) of 4 sampled residents. The facility census was 37. Findings are: Review of a facility document labeled Constipation Prevention dated 08/01/2023 revealed an as needed laxative, which is a medication administered to promote bowel movements, will be offered during the third day without a bowel movement. A suppository will be offered the morning of the fourth day without a bowel movement. If a resident does not have a bowel movement after an as needed laxative and a suppository is provided, and assessment of the abdomen, bowel sounds, pain and appetite will be completed. The primary physician will be notified. A review of an admission Record dated 5/14/24 indicated the facility admitted Resident #19 on 04/20/2024 with diagnoses of Schizophrenia which is severe mental health disorder that can result in hallucinations, delusions, and extremely disorder thinking and behavior that interfere with daily life, compression fracture…

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 Licensure Reference Number 175 NAC 12-006.09D Based on record review and interviews; the facility staff failed to manage complaints of pain for 1 (Resident 192) of 2 sampled residents. The facility staff identified a census of 37. Findings are: Record review of the admission Record dated 5/14/24 for Resident 192 revealed that Resident 192 admitted into the facility on [DATE] with a diagnosis of the following: -Closed left subtrochanteric femur fracture (break in thigh bone) -Pelvic fracture (to the hip bones, sacrum, or coccyx) -Diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired) -Obesity (abnormal or excessive fat accumulation that presents a risk to health) -Hyperlipidemia (abnormally high concentration of fats in the blood) -Hypertension (pressure in the blood vessels are too high) -COPD (condition involving constriction of the airways in breathing) -Chief Complaint: PAIN Record review of Resident 192's Minimum Data Set (MDS, a federally mandated…

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 G. Record Review of the Administrative admission Packet, dated 3/2/23, revealed Resident 27 was admitted to facility on 3/2/23. Record review of nursing notes dated 3/16/23 at 5:20 PM revealed Resident 27 was sent to ER. Record review of a nursing note dated 3/17/23 at 1:03 PM revealed that Resident 27 returned to the facility. Record review of Resident 27's medical record revealed no documentation that the Ombudsman was notified of Resident 27's transfer to the hospital. Record Review of MDS (Minimum Data Set- an assessment that gives a summary of resident's health and condition) dated 3/16/23 revealed that resident discharged with return anticipated H. Record review of Resident 27's Nursing note dated 3/28/23 revealed that the resident was sent to the hospital on 3/27/23 following a follow up appointment with the Primary Care Provider for Resident 27. Record review of Nursing note for Resident 27 dated 3/31/23 revealed that resident was assessed in facility. Record review of MDS dated [DATE] revealed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure that a required written bed hold notification (written information outlining options for holding or reserving a resident's bed while the resident is absent from the facility for hospitalization) was provided to the resident/resident representative at the time of transfer for 5 residents (Residents 16, 28, 36, 18, and 27). This prevented the resident/resident representative from making an informed decision to either request a bed hold (a reservation that allows a resident to return to the facility) or release the resident bed. The facility census was 37. Findings are: A. Record review of Resident 16's Discharge Return Anticipated MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) revealed Resident 16 was admitted to the facility on [DATE] and was discharged to the hospital on 4/16/2023. Review of Resident 16's Progress Notes dated 4/11/2023 to 5/11/2023 revealed documentation Resident 16 was transferred to the…

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

Licensure Reference Number 175NAC 12-006.11E Based on observation, interview, and record review; the facility failed to maintain the ice and water dispenser machine to prevent the potential for foodborne illness. This had the potential to affect 33 residents who received thin liquids; and the facility failed to ensure that dietary staff handled dishware to prevent the potential for cross contamination and foodborne illness for 4 residents (Residents 140, 1, 21, and 36). The facility census was 37. Findings are: A. Observation of the facility dining room on 5/10/23 at 8:19 AM revealed an ice and water dispenser machine was sitting on the counter in the dining room. There was white, gray, and brown material on the outside of the machine, on the ice dispenser nozzle, and on the grate over the drain. At 12:10 PM an unidentified staff member filled a glass of ice water out of the machine in the dining room then gave it to Resident 23 who then proceeded to drink it. Observation of the ice and water dispenser machine in the dining room on 5/11/23 at 3:30 PM with the VPCS (Vice President 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.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation and interview, the facility failed to maintain equipment to prevent a potential accident hazard for 1 of 6 sampled residents, Resident 5. The facility identified a census of 37 at the time of survey. Findings are: Review of Resident 5's quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 4/9/2023 revealed an admission date of 7/7/2021. Resident 5 was independent with bed mobility, transfers, and walking in the room and required limited assistance from 1 staff person for toilet use. Observation of Resident 5's bathroom on 05/10/23 at 10:47 AM revealed the toilet riser was not secured to the toilet. The toilet riser sat down in the toilet bowl and was loose and could easily be moved with light pressure of the hand which created a potential accident hazard in the event the toilet riser would become ajar while the resident was sitting on it causing the resident to fall off the toilet. Observation of Resident 5's bathroom on 5/10/2023 at 4:01 PM with the facility DON…

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.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observation, interview, and record review; the facility failed to maintain food temperatures to preserve palatability and prevent the potential for foodborne illness. This affected 1 of 1 sampled residents. The facility identified a census of 37 at the time of survey. Findings are: Interview with Resident 36 on 05/10/23 at 10:08 AM revealed they ate their meals in their room. Resident 36 revealed the hot food was often cold when they received it and they were at the end of the hall and were the last one served. Observation on 5/15/23 at 12:28 PM revealed that the noon meal test tray was provided by DC-D (Dietary Cook). The diced carrots on the plate had a temperature of 149.7 F (Fahrenheit). The fried potatoes (potatoes that were cut in thick slices with some end pieces of potatoes that were in chunks) had a temperature of 119.1 F. The smothered chicken (a flat piece of whole meat chicken breast with a clear sauce on it) had a temperature of 129.2 F. Taste test of the chicken revealed it had a grainy consistency and tasted luke…

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.