Homeplace Manor Healthcare Center

Based on interviews and record reviews, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 9 of 15 (the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on HIV, restraint reduction and prevention of falls. The facility failed to implement and maintain a training program that ensured the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H received required HIV training upon hire. The facility failed to implement and maintain a training program that ensured the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H received required restraint reduction training upon hire.The facility failed to implement and maintain a training program that ensured the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H received required prevention of falls training upon hire. These failures could place residents at risk of being cared for by staff who had been insufficiently trained on the mode of HIV transmission, HIV prevention, behaviors…

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 interviews and record reviews, the facility failed to include effective communications as mandatory training for direct care staff all new and existing staff for 8 of 15 (the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on effective communication. The facility failed to ensure communication training was provided to the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H upon hire. This failure could place residents at risk of not understanding their total health status and not effectively being provided notice of rights and services both orally and in writing in a manner that the resident understands.Findings includedRecord review of personnel record for the AIT reflected a hire date of 10/17/2025. Further review of personnel record provided by the BO reflected the AIT had no evidence she had completed required effective communication training upon hire or while working at the facility.Record review of personnel record for the SW reflected a hire date of 3/01/2025. Further review of personnel record provided by the BO…

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 interviews and record reviews, the facility failed to ensure staff members were educated on the rights of the resident and the responsibilities of a facility to properly care for its residents. for all new and existing staff for 9 of 15 (the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on resident's rights. The facility failed to ensure that the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on the rights of the resident, and the responsibilities of the facility to properly care for its residents upon hire.This failure could place residents at risk of their rights not being honored by uninformed staff. Findings includedRecord review of personnel record for the AIT reflected a hire date of 10/17/2025. Further review of personnel record provided by the BO reflected the AIT had no evidence she had completed required resident rights training upon hire or while working at the facility.Record review of personnel record for the SW reflected a hire date of 3/01/2025. Further review of personnel…

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 interviews and record reviews, the facility failed to provide training to their staff that at a minimum educates staff on (1) activities that constitute ANE and misappropriation of resident property: (2) procedures for reporting incidents of ANE or misappropriation of resident property; (3) dementia management and resident abuse prevention for all new and existing staff for 9 of 15 (the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on abuse, neglect, and exploitation and training for dementia management. The facility failed to ensure the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on abuse, neglect and exploitation & dementia management upon hire. These failures could place residents at risk of being abused, neglected, or exploited by uninformed staff and could delay the facility's investigation of abuse, neglect, or exploitation. Findings includedRecord review of personnel record for the AIT reflected a hire date of 10/17/2025. Further review of personnel record provided by the BO…

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 interviews and record reviews, the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff on the elements and goals of the facility QAPI program for all new and existing staff for 9 of 15 (the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on QAPI. The facility failed to ensure that the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on the facility's QAPI program upon hire. This failure could place residents at risk of their quality of care not being improved upon when a known issue had occurred from staff not being informed on the goals and various elements of the QAPI program. Findings includedRecord review of personnel record for the AIT reflected a hire date of 10/17/2025. Further review of personnel record provided by the BO reflected the AIT had no evidence she had completed QAPI training upon hire or while working at the facility.Record review of personnel record for the SW reflected a hire date of 3/01/2025. Further review of…

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

Based on interviews and record reviews, the facility failed to include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program for all new and existing staff for 8 of 15 (the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on infection control. The facility failed to ensure the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on infection control upon hire. This failure could place residents at risk of contracting facility acquired infections from staff not being informed on proper infection prevention and control practices when performing resident care activities that pertain to that staff member's role.Findings includedRecord review of personnel record for the AIT reflected a hire date of 10/17/2025. Further review of personnel record provided by the BO reflected the AIT had no evidence she had completed infection control training upon hire or while working at the facility.Record review of personnel record for the SW…

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 interviews and record reviews, the facility failed to include as part of its compliance and ethics program (1) an effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program; (2) annual training if the operating organization operates 5 or more facilities for all new and existing staff for 8 of 15 (the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H) reviewed for training on compliance and ethics.The facility failed to ensure that the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on compliance and ethics upon hire.This failure could affect residents and place them at risk of being uninformed of compliance and ethics program due to lack of staff training.Findings includedRecord review of personnel record for the AIT reflected a hire date of 10/17/2025. Further review of personnel record provided by the BO reflected the AIT had no evidence she had completed compliance and ethics training upon hire or while working…

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 interviews and record reviews, the facility failed to provide behavioral health training consistent with the requirements at 483.40 (behavioral health services) and as determined by the facility assessment for 8 of 15 (the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on behavioral health. The facility failed to ensure that the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on behavioral health upon hire. This failure could place residents diagnosed with a mental, psychosocial, or substance use disorder at risk of not receiving the care specific to their individual needs.Findings were:Record review of personnel record for the AIT reflected a hire date of 10/17/2025. Further review of personnel record provided by the BO reflected the AIT had no evidence she had completed behavioral health training upon hire or while working at the facility.Record review of personnel record for the SW reflected a hire date of 3/01/2025. Further review of personnel record provided by the BO reflected the SW had no evidence he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives to meet resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #10 and Resident #15) of 12 residents reviewed for comprehensive person-centered care plans. 1. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of hospice services for Resident #10. 2. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of insulin and diabetes for Resident #15. This failure could place the residents at risk for decreased quality of life and not having their needs met.Findings include: Resident #10 Review of Resident #10's electronic face sheet accessed on 12/18/2025, revealed an [AGE] year-old male readmitted to the facility on [DATE] with diagnoses to include: Alzheimer's disease, fracture 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 observation, interview, and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 1 lunch meal reviewed. This facility failed to follow the menu when preparing lunch meal on 09/02/2024. This failure could place residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake. The findings include: Record review of Resident #5's Face Sheet revealed an [AGE] year-old female who was admitted on [DATE] with Diagnoses that included: Nausea and Vomiting, Dietary Calcium Deficiency, Hypokalemia (low potassium), Vitamin D deficiency, Generalized Anxiety order. Record review of Resident #5's Physician orders dated 09/01/2024 revealed: Regular Diet with regular texture. Record review of Resident #5's Quarterly MDS dated [DATE] revealed: Section C-Cognitive Patterns BIMS score was 10…

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, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety of 1of 1 kitchens reviewed. The facility failed to ensure items stored in 1 of 1 freezer were properly stored and labeled. The facility failed to ensure current temperature logs of 1 of 1 freezer and 2 of 2 refrigerators were maintained daily. The facility failed to ensure dietary staff (1 of 2) wore hair nets when preparing, serving meals. These failures could place resident that eat out of the kitchen at risk for food borne illnesses. The findings include: During an observation on 09/02/2024 at 09:55 AM in the kitchen revealed temperature logs for 1 of 1 freezer and 2 of 2 refrigerators were not up to date. There were no temperature logs for September 2024. During an observation on 09/02/2024 at 09:58 AM dietary staff were not wearing a hair net. During an observation on 09/02/2024 at 10:00 AM revealed in the freezer 1 box of tamales not sealed, dated. One package of what appeared to be…

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

Based on interview and record review, the facility failed to ensure employees received the required training effective communications mandatory training was completed for 7 of 19 employees (DON, DM, MAINT, CNA C, TRNS, COTA, and HSKP F) reviewed for training. The facility did not ensure effective communication training was completed by the DON, MAINT, TRNS, and COTA during orientation. The facility did not ensure effective communication training was completed by the DM, CNA C, and HSKP F annually. These failures could place residents at risk of miscommunication and social isolation due to lack of staff training. Findings included: Record review of the employee files revealed no evidence the following staff had completed effective communications training during orientation: * DON hire date 06/03/2024; * MAINT, hire date 09/28/2023; * TRNS, hire date 03/27/2024; * COTA, transferred from a sister facility on 08/23/2024 Record review of the employee files revealed no evidence the following staff had completed effective communications training annually: * DM, hire date 08/03/2022; * CNA…

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

Based on interview and record review, the facility failed to ensure the staff members were educated on the rights of the resident and the responsibilities of the facility to properly care for its residents for 5 of 19 staff (DM, LVN G, HSKP E, TRNS, and HSKP F) reviewed for training requirements in that: The facility failed to ensure five staff which included: DM, LVN G, HSKP E, TRNS, and HSKP F received the required training on resident rights timely. This failure could place residents at risk of receiving care from staff who were insufficiently trained. The findings included: Record review of the DM's employee file revealed a hire date of 08/03/2022. The file did not contain any record of training on resident's rights. Record review of LVN G's employee file revealed a hire date of 09/04/2023. The file did not contain any record of training on resident's rights. Record review of HSKP E's employee file revealed a hire date of 08/05/2024. The file did not contain any record of training on resident's rights. Record review of TRNS's employee file revealed a hire date of 08/23/2024. 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 training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property and dementia management for 2 (DM and HSKP F) of 19 employees reviewed for staff training. The facility failed to have documentation for DM and HSKP F on what constitutes abuse, neglect, exploitation, misappropriation of resident property and how to report the above. These failures could place residents at risk of injury or harm due to being cared for by untrained staff. Findings included: Record review of the DM's employee file revealed a hire date of 08/03/2022. The file did not contain any record of training on abuse, neglect, exploitation, misappropriation of resident property. Record review of HSKP F's employee file revealed a hire date of 04/01/2023. The file did not contain any record of training on abuse, neglect, exploitation,…

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

Based on interview and record review, the facility failed to ensure standards, policies, and procedures for an infection prevention and control program was completed for 3 of 19 staff (DM, HSKP E, and HSKP F) reviewed for training. The facility failed to ensure five staff which included the DM, HSKP E, or HSKP F received the required training on infection control timely. These failures could place residents at risk of illness due to lack of staff training. Findings included: Record review of the DM's employee file revealed a hire date of 08/03/2022. The file did not contain any record of training on infection control. Record review of HSKP E's employee file revealed a hire date of 08/05/2024. The file did not contain any record of training on infection control. Record review of HSKP F's employee file revealed a hire date of 04/01/2023. The file did not contain any record of training on infection control. During an interview on 09/04/24 at 12:32 p.m., the DM stated training was done online. He explained that staff received email notices and group text when trainings were available…

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 develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 1 (Resident #24) of 14 residents reviewed for care plan completion. 1. The facility failed to complete Resident #24's baseline care plan within the required 48-hour timeframe. 2. The facility failed to provide Resident #24 a summary of their baseline care plan after completion. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified. Findings included: Record review of Resident #24's electronic face sheet dated 09/04/2024 revealed the resident was a [AGE] year-old male admitted on [DATE]. Record review of Resident #24's quarterly MDS dated [DATE] revealed: BIMS score of 09 which indicated moderate cognitive impairment. Record review…

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 complete a performance review of each CNA at least once every 12 months, for 1 of 3 (CNA C) reviewed for annual competency evaluations. The facility failed to complete annual CNA competency evaluations for CNA C, based on the personnel file review results. This failure could affect residents by placing them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs. Findings included: Record review of the Personnel File Review completed on 09/04/2024, indicated CNA B, did not have a competency evaluation on file. The Personnel File Review indicated CNA B's date of hire was 03/27/2023. During an interview on 09/04/2024 at 2:25 p.m., the CRN stated the DON was responsible for conducting and documenting nursing training and staff performance reviews. She stated the effect on residents would depend the topic of the review and impact on the quality of care and life for the resident. The CRN explained the facility had recently changed from paper records to electronic records and had 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 record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months (October 2023, November 2023, and December 2023) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, 7 days a week for the months of October 2023, November 2023, and December 2023 (Saturday's and Sunday's) for a total of 22 days. This failure could place the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings include: Record review of the CMS' PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 1, 2024 (October 1, 2023 - December 31, 2023), run date 05/29/2024, revealed no evidence of RN coverage for Saturday's and Sunday's for the months of October…

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 reviews, the facility failed to establish and 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 for 1(Resident #1) of 3 residents reviewed for infection control practice. CNA (Certified Nurse Aide) A failed to perform hand hygiene and change her gloves at the appropriate times while providing incontinence care for Resident #1. These failures could place residents at risk for the spread of infection. Finding include: Review of Resident #1's face sheet, dated 05/30/24, revealed the resident was a 91- year- old female admitted to the facility on [DATE] with diagnoses of diarrhea, rash, and other nonspecific skin eruptions, and need for personal care. Review of Resident #1's Minimum Data Set (MDS) assessment, dated 05/01/24, revealed Resident #1 required moderate assistance with most activities of daily living (ADL)) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week or designate a registered nurse to serve as the director of nursing on a full-time basis. The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day. The facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis. These failures placed all residents at risk of their clinical needs not being met. Findings included: Record review of PBJ report ran 07/11/23 for Fiscal Year Quarter 2 (January 1,2023 to March 31, 2023) revealed no RN coverage for 01/01 (SU); 01/02 (MO); 01/03 (TU); 01/04 (WE); 01/05 (TH); 01/06 (FR); 01/07 (SA); 01/08 (SU); 01/09 (MO); 01/10 (TU); 01/11 (WE); 01/12 (TH); 01/13 (FR); 01/14 (SA); 01/15 (SU); 01/16 (MO); 01/17 (TU); 01/18 (WE); 01/19 (TH); 01/20 (FR); 01/21 (SA); 01/22 (SU); 01/23 (MO); 01/24 (TU); 01/25 (WE); 01/26 (TH); 01/27 (FR); 01/28 (SA);…

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

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to appropriately label, date, seal/close items stored in pantry, refrigerator, and freezer. The failure could place residents at risk for food-borne illness from food contamination. Findings include: During an observation in the facility's only kitchen on 07/24/2023 from 09:40 AM to 10:15 AM revealed the following: Four containers of spices on a shelf had lids open to air: Lemon pepper, sea salt, garlic powder, ground cumin. One 32-oz open bag of cheese sauce mix half full, folded over once and with no date of when opened One 32-oz open bag of potato flakes with no date of when opened One 1 lb. 8 oz bag of fried onions with no date of when opened One 5 lb. white cake mix was open to air with no date of when opened One 5 lb. bag of devil's food cake mix, half full, wrapped in clear plastic with no date of when opened One 5 lb. bag of blueberry muffin…

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 care plans were reviewed and revised by the interdisciplinary team after each assessment for 6 of 13 Residents (Residents #1, # 12, #19, #22, #24, #25) reviewed for comprehensive care plans, in that; The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #1's comprehensive assessment on 07/11/2023. The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #12's comprehensive assessment on 06/30/2023. The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #19's comprehensive assessment on 07/01/2023. The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #22's comprehensive assessment on 07/11/2023. The facility failed to develop a comprehensive care plan without…

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 reviews the facility failed to maintain an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 6 of 7 months reviewed for antibiotic stewardship. The facility failed to maintain a system to monitor antibiotic use during the months of January 2023 through June 2023. These failures placed residents at risk of adverse outcomes associated with the inappropriate use of antibiotics. Findings included: Record review of Facility Infection Control Log for January 2023 through July 2023 revealed facility maps with color coded rooms and the legend revealed the color to coordinate with the type of infection. There was also a page for each month that included each resident order for that corresponding month of a resident with an abx. There was no tracking form for the months of January 2023 through June 2023 that included if a resident had a lab completed before starting an abx, if they met/didn't meet the McGreers criteria for abx therapy, or if the infections were facility or community acquired. During…

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.