Windflower Health Center

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 2 of 2 kitchens when they failed to: A. Ensure stored food was properly labeled, dated and covered. B. Ensure general cleanliness was maintained. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: In an observation on 4/9/25 at 8:20 am, Kitchen # 2 was located inside the LTC facility and had capabilities of storing and preparing food items for the LTC, as well as a steam table for plating and serving foods. In an observation on 4/9/25 at 8;22 am, of the kitchen prep area for Kitchen #2, the following was observed: 1. Food crumbs and spills were observed in the bottom of the 4-door cooler. All 4 door handles were grimy and sticky to the touch. 2. The utensil drawer had food crumbs and debris inside the drawer holding the cooking utensils. There were 5 dirty food caked utensils with food debris inside the drawer with clean utensils. 3. The toaster had food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, administering, and documentation of all drugs and biologicals) to meet the needs of 1 out of 5 residents (Residents #8) who was observed for medication administration. -RN I administered medication to Resident #8 via nebulizer and left Resident #8 unattended. These deficient practices can affect residents that receive medications resulting in adverse reactions to medication, deterioration in their health, exacerbation of their disease process, and/or hospitalization. Findings included: Record review of Resident #8's face sheet, dated 04/11/2025, revealed Resident #8 was an [AGE] year-old female resident who was admitted to the facility on [DATE]. Resident #8 had diagnoses of, but not limited to, parainfluenza virus pneumonia, unspecified asthma with acute exacerbation (a sudden worsening of asthma symptoms characterized by…

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 record review, the facility failed to store and label drugs and biologics in accordance with professional principles, and include the appropriate accessory and cautionary instructions and the expiration date when applicable to meet the needs of for 1 of 17 (Resident #6,) and 1 of 5 medication carts (LTC Side B medication cart), and 2 of 2 (rehab side and LTC/MC side)medication storage rooms under review. -Medication cart for B side of LTC had a box of anti-diarrheal with an expiration date of 02/2025. -Resident #6's Albuterol inhaler had an expiration date of 01/2025, and a Breo Ellipta inhaler with no open date on medication. -Medication cart for A side of LTC had a box of acid reducer with an expiration date of 12/2024. -Medication cart for A side of LTC had bottle of Geri-Tussin with an expiration date of 03/2025. -Medication cart for Back of Rehab had glucometer control solution with an expiration date of 09/30/2024. -Rehab medication room had 3 bottles of B-Complex with an expiration date of 03/2025, and 1 bottle of Glucosamine Chondroitin complex with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 6 (LVN C, CNA F, CNA G, and RNI) staff observed for resident care. -LVN C did not perform hand hygiene, use PPE or sterile technique (to minimize the number of microbes present to as few as possible) to flush Resident #27's suprapubic catheter. -CNA F did not change gloves or perform hand hygiene during incontinent care of Resident #60. -CNA G did not change gloves or perform hand hygiene during incontinent care of Resident #60. -EBP signage or PPE for EBP was in place for Resident #319, who has a PICC line. -RN I did not use PPE while administering IV medications via PICC line for Resident #319. -RN I dumped Resident #8's medication down the bathroom sink. These deficient practices affect all residents in the facility by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 17 (Resident #60) residents reviewed for PASRR. Resident #60 was not referred for PASRR Level II Assessment when a diagnosis of Mental Illness was identified on 07/03/2024. This failure could affect residents with mental illnesses and placed them at risk of not being assessed to receive needed services. Findings included: Record review of Resident #60's clinical record face sheet dated 4/09/2025 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic systolic (congestive) heart failure, type 2 diabetes mellitus without complications (high blood sugar), schizoaffective disorder-bipolar type ( hallucinations and delusion with mood), alcohol dependence, anxiety disorder, and partial traumatic amputation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #114) of 17 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address Resident #114's pain and the appropriate interventions. This failure could place residents at risk of not receiving desired and necessary care and treatment. Findings Included: Record review of Resident #114's admission record dated 04/09/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses 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 observation, interview, and record review the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #39) of 17 residents reviewed for oxygen thearpy. The facility failed to ensure Resident #39 had physician's order in his chart for oxygen. This failure could place residents at risk of having records that do not reflect their current status or needs. Findings Included: Record review of Resident #39's Face Sheet dated 04/10/2025 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, encounter for orthopedic aftercare following surgical amputation, acquired absence of left leg above knee, type 2 diabetes mellitus (high blood sugar), chronic obstructive pulmonary disease (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems), peripheral vascular disease (blood circulation disorder), heart failure,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to assess residents for risk of entrapment from bed rails prior to installation. The facility failed to review the risks and benefits of bed rails with 1 (Resident #319) of 17 residents or their resident representatives and obtain informed consent prior to installation of bed rails. Resident #319 had (2) one-quarter bed rails, one on each side of his bed with no documentation of consent or safety assessment prior to installation. This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living. Findings included: Record Review of Resident #319's Face Sheet dated 04/10/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems), chronic atrial fibrillation (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintatined periodically reconciled for 3 of 10 residents (Resident #2, Resident #5, and Resident #6) reviewed for pharmacy services. 1. The facility failed to prevent LVN B from misplacing narcotics for Resident #2, Resident #5, and Resident #6. 2. The facility failed to ensure Resident #2, #5, and #6's narcotics medications were accounted for: 2 out of the 3 narcotics that were missing. These failures could place residents at risk of not receiving medication therapy that would be effective for their treatment, resulting in the exacerbation of conditions and disease processes. Findings include: Resident #2: Record review of Resident #2's clinical record, dated 04/02/2025, revealed she was a [AGE] year-old female resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have acess to the keys for 3 of 10 residents (Resident #2, Resident #5, and Resident #6) reviewed for medication storage. -The facility failed to ensure LVN B stayed with Resident #6 until narcotic medications were taken. -The facility failed to ensure LVN B did not place narcotics in the nightstand table of Resident #5 and Resident #6's meal tray. -The facility failed to ensure LVN B did not destroy narcotic medications for Resident #2, by throwing them away in the medication cart trash can. These failures could place residents at risk for drug diversion, lack of drug efficacy, and adverse reactions. Findings included: During an interview on 04/01/2025 at 9:50am CNA A stated she saw LVN B throw narcotics into the trash can on the medication cart. CNA A stated 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 interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by the resident assessments and infividual plans of care considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 1 of 5 (LVN B) staff reviewed for nursing services. The facility failed to ensure that LVN B distributed and destroyed narcotic medications in accordance with professional standards and facility policy. This failure could place residents at risk for drug diversion, lack of drug efficacy, and adverse reactions. Findings include: During an interview on 04/01/2025 at 9:50am CNA A stated she saw LVN B throw narcotics into the trash can on the medication cart. CNA A stated to LVN B there was drug buster and that was how narcotics were destroyed. CNA A stated that LVN B told her…

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 immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representatives when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention or a significant change in the resident's physical, mental, psychosocial status for 1 (Resident #1) of 6 residents reviewed for notification. The facility failed to ensure Resident #1's resident representative was immediately notified when the resident had a change in condition that required her to be transported via ambulance to the hospital. This failure could result in residents not having the comfort and company of their families during traumatic times. Findings included: Record review of Resident #1's admission record dated 06/30/24 indicated that she was an [AGE] year-old female, who was admitted into the facility on [DATE]. Resident #1 had diagnoses that included but…

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 ensure each resident has a right to a dignified existence and to treat each resident with respect and dignity for 1 (Resident #324) of 27 residents reviewed for resident's rights. The facility failed to keep Resident #324's catheter bag covered with a privacy bag. This failure could lead to residents at risk of experiencing feelings of shame and/or embarrassment as well as having their right to privacy violated. Findings include: Record review of Resident #324's face sheet dated 02/26/24 revealed a [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses that included, but were not limited to, chronic congestive heart failure (fluid around the heart), acute respiratory failure (sudden failure of lungs to deliver oxygen to the body), type 2 diabetes mellitus without complications (high blood sugar), morbid obesity, depression, muscle weakness, encounter for fitting and adjustment of urinary device, and need for assistance…

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 ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknow source and misappropriation of resident property, are reported immediately, but not later than 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, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident # 126) of 18 residents reviewed for abuse. A CNA failed to report to the Abuse Prevention Coordinator an allegation of verbal abuse made by Resident #126 regarding another CNA. This failure could…

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 and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours of a resident's admission, include the minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASRR recommendation for 1 (Resident #73) of 3 closed resident records reviewed for baseline care plans. The facility failed to develop a baseline care plan for Resident #73 that addressed his diagnoses and physician's orders. This failure could place newly admitted residents at risk of not receiving necessary care. Findings Included: Record review of Resident #73's admission MDS completed on 12/28/23 revealed a [AGE]…

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 implement a comprehensive 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 comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 18 Residents (Resident #55 and #65) reviewed for comprehensive care plans. - The facility failed to update the code status in the comprehensive person-centered care plan for Resident #55. - The facility failed to include code status in the comprehensive person-centered care plan for Resident #65. This failure could affect all residents in the facility receiving care per comprehensive person-centered care plans resulting in resident not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Finding…

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 attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for one (Resident #126) of 18 residents reviewed for bed rails. Resident #126 had quarter bed rails on both sides of her bed with an assessment that indicated no use of bed rails and no consent in the EHR. This failure could place residents at risk of entrapment or injury. Findings Included: Record review of Resident #126's admission record dated 02/27/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement), hemiplegia (partial…

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

Based on observation, interview, and record review it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 of 3 Medication Carts (East side cart #1 and East side cart #2) in that: 1 expired medication found in Medication Cart #1 on East side of building. 23 expired oral (buccal) dose of medication, 1 packaged medication without an expiration date, 1 box of expired medication, and 6 loose pills were found in Medication Cart #2 on East side of building. The facility's failure to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, medications that have been compromised could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level. Findings include: Observation on 02/26/24 at 09:16AM of Medication Cart #1 East side of building with MA E,…

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, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #324) of 27 residents reviewed for accurate medical records. The facility failed to correctly transcribe the Nurse Practitioner orders for Resident #324 related to blood sugar. This failure could place resident at risk of not receiving needed care or treatments by misleading care providers regarding what care or treatment resident should receive. The findings include: Record review of Resident #324's face sheet dated 02/26/24 revealed a [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses that included, but were not limited to, chronic congestive heart failure (fluid around the heart), acute respiratory failure (sudden failure of lungs to deliver oxygen to the body), type 2 diabetes mellitus without complications…

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 residents were free of any significant medication errors for one of 6 (Resident #1) residents reviewed for medication administration. -Resident #1 received Propranolol HCl oral tablet 20mg, over the course of 8 days, without an order. This failure could place residents who receive blood pressure medications at an increased risk for complications such as decreased blood pressure, decrease pulse, and an exacerbation of symptoms and disease process. Findings include: Record review of Resident #1's face sheet revealed an [AGE] year-old female re-admitted on [DATE] with diagnoses that included, but were not limited to, hypertensive urgency, essential hypertension, essential tremor, depression, anxiety disorder, muscle weakness and atrophy, not elsewhere classified, fibromyalgia, cognitive communication deficit, pain, unspecified fall, subsequent encounter, syncope and collapse, acute kidney failure. Record review of Resident #1's current MDS…

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.

F812 Abreviations: lbs- pounds, DM- Dietary Mananger, Admin- Administrator, DD- Dietary Director Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 2 of 2 kitchens (Kitchen A, Kitchen B) reviewed for proper protocols. 1. The facility failed to ensure stored foods are properly labeled and dated putting residents at risk for foodborne illness. 2. The facility failed to ensure proper temperature of hot and cold food items putting residents at risk for foodborne illness. 3. The facility failed to serve residents food that was at the proper holding temperature putting residents at risk for foodborne illness. Findings Include: Observation of Facility Fridge A in Kitchen A on 8/21/2023 at 11:16AM revealed the following: 1. 5lb container of garlic opened with no open date 2. 5lb container of jalapenos opened with no open date 3. 5lb container yellow mustard opened with no open date 4. 5lb container tartar sauce opened with no open date, expired on 7/30/2023…

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.