Munday Nursing Center

Based on observation, interview, and record review, the facility failed to make information available to resident's and their representatives on filing grievances or concerns for 6 of 8 confidential residents reviewed for grievances. The facility failed to ensure 6 of 8 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, access to Grievance forms, information regarding who the facility Grievance officer was with their contact information, and accommodations to file an anonymous Grievance. The facility failed to include all areas per the regulation in their Grievance Procedures policy, to include the following: This failure could place the residents at risk of unresolved Grievances and decreased quality of life. Findings include: During a confidential interview on 06/25/2025 at 1:30 PM with the resident council, 6 confidential residents stated they did not know how to file a formal Grievance. The residents stated they did not have access to Grievance forms, and they did not know where Grievance forms were kept. The residents stated…

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 review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 3 of 14 residents (Residents #1, #4, #42) reviewed for care plans. The facility failed to develop an accurate, consistent, and completed care plan for Residents #1, #4 and #42 in regard to the residents being placed on hospice services. This failure could place residents at risk of not receiving the care required to meet their individualized needs. Findings included: Resident #1 Record review of the face sheet revealed Resident #1 was admitted to the facility on [DATE], with a readmission on [DATE]. Resident #1 was an [AGE] year-old female with diagnoses that included the following: Unspecified dementia (the specific type -like Alzheimer's or vascular…

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 1 of 1 kitchen (Kitchen A) reviewed for dietary services. 1) The DM failed to clean the food thermometer each time before placing in a food item. 2) [NAME] A failed to serve a cold food in the proper temperature for serving, below 41 degrees Fahrenheit (F). These failures could place residents at risk for food contamination and foodborne illness. The findings include: Observation on 06/24/25 at 11:49 AM during the food temping process for the noon meal, the DM placed a dial food thermometer in the puree macaroni salad without cleaning the probe first. The DM then placed the dial food thermometer in an ice bath for calibration and the thermometer was then placed in the puree sandwich without cleaning the probe first. The DM then cleaned the dial food thermometer with an alcohol prep pad and was then placed back in the ice bath. The DM then placed the dial food thermometer back in the puree macaroni…

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 and ensure safe and sanitary storage of residents' food items for 7 of 7 residents rooms reviewed for food safety (room [ROOM NUMBER], #5, #9, #11, #29, #31, and #32) in that: The refrigerator located in room [ROOM NUMBER], #5, #9, #11, #29, #31, and #32 were not being monitored for internal temperature and expiration/used by dates. These failures could place residents at risk for food borne illnesses. Findings include: During an observation on 06/24/2025 at 09:52 AM, Resident room [ROOM NUMBER] contained a personal refrigerator. The refrigerator contained perishable food items such as ice cream. The expiration date on the individual ice cream was not legible, as the ink was smeared. The freezer portion of the refrigerator had a large amount of frost build up. The refrigerator also contained bottles of water and cans of soda. During an observation on 06/24/2025 at 09:58 AM, Resident room [ROOM NUMBER] contained a personal…

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 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure foods were labelled and dated. These failures could place residents at risk for food-borne diseases and food contamination. The findings included: - The following observation was made during a kitchen tour on 05/14/24 that began at 09:41 AM and concluded at 10:56 AM: - Dirty and sticky doors of 2 freezers and 1 refrigerator. - Undated and unlabeled hot dogs inside the freezer. - Undated and unlabeled Baloney inside the freezer. - Undated and unlabeled Ham inside the freezer. - Undated and unlabeled Fish inside the freezer. - Undated and unlabeled Pancakes inside the freezer. - Undated and unlabeled Hamburger Patties inside the freezer. - Undated and unlabeled Garlic Sticks inside the freezer. - Undated and unlabeled Mixed Vegetables inside the freezer. - Undated and unlabeled Omelets inside the freezer. - Undated 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 review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 4 of 40 residents (Residents #7, #17, #19, and #23) reviewed for PASRR screening, in that: Residents #7, #17, #19, and #23 did not have an accurate PASRR Level 1 assessment when they have a diagnosis of mental illness. These failures could place residents with an inaccurate PASRR Level 1 and no PASRR Level 2 Evaluation at risk for not receiving care and services to meet their needs. The findings were as follows: Resident #7: Record review of Resident #7's electronic face sheet dated 5/15/2024 revealed an [AGE] year-old female, admitted to the facility on [DATE]. The face sheet indicated, under Diagnosis Information, a diagnosis of Major Depressive Disorder. Record review of Resident #7's Quarterly MDS assessment dated [DATE], revealed under Section C Cognitive Patterns, a BIMS score of 10 indicating…

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, record review and interview, the facility failed to develop a comprehensive care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 4 of 15 residents (Residents #11, #13, #14, and #23) reviewed for care plans as follows: The facility failed to develop a care plan for vision for Resident #11. The facility failed to develop a care plan for smoking and psychotropic medications for Resident #13. The facility failed to develop a care plan for advanced directives for Resident #14. The facility failed to develop a care plan for smoking for Resident #23. These failures could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings include: Resident #11 Record review of the admission record for Resident #11 dated 05/15/24 revealed an [AGE] year-old female who was…

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 ensure the residents had the right to participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 1 of 15 residents (Residents #1) reviewed for resident rights. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Residents #1 prior to administering Celexa, Lorazepam, and Seroquel, psychotropic medications, (a psychoactive drug taken to exert an effect on the chemical make-up of the brain and nervous system). This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the benefits and risks of the medications prescribed.…

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 all residents had the right to formulate an advance directive for 3 of 15 residents (Residents #5, #13, and #30) reviewed for advanced directives, in that: Residents #5, #13, and #30 were listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. These failures could place residents at risk for not having their end of life wishes honored and incomplete records. Findings included: Resident #5 Record review of Resident #5's current undated face sheet revealed an [AGE] year-old-female who was admitted to the facility on [DATE] with a primary diagnosis of dementia. Additionally, the advance directive was listed as OOH-DNR. Record review of Resident #5's physician order summary dated [DATE] revealed physician orders listed as do not resuscitate, dated [DATE]. Record review of Resident #5's care plan dated [DATE] revealed a care plan goal for…

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 1 of 16 residents (Resident #30) and 1 of 3 staff (CNA A ) reviewed for infection control. 1. CNA A failed to change gloves when providing incontinent care for Resident #30. This failure could place residents at risk for spread of infection and cross contamination. Findings include: 1. Record review of Resident #30's face sheet, dated 05/16/24, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: unspecified dementia (loss of intellectual functioning), major depressive disorder (persistent low or depressed mood), neuromuscular dysfunction of bladder, (lack of bladder control due to brain or nerve problems), hypertension (elevated blood pressure), atherosclerotic heart disease (damage 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 Resident #1 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days, in that two of seven residents (Resident #1 and Resident #47) continued to receive psychotropic medications PRN for more than 14 days without a physician addressing the continued use of the medication: - Resident #1 continued to have a PRN order for Lorazepam 1mg after 14 days without an evaluation by the physician for continued treatment. - Resident #33 continued to have a PRN order for Xanax 0.5mg after 14 days without an evaluation by the physician for continued treatment. This failure could result in residents receiving psychotropic and antipsychotic medications when contraindicated and could also result in residents experiencing adverse drug reactions. 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 observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for residents who consumed food orally from 1 of 1 facility kitchen in that: Perishable ready to eat foods were held beyond safe use dates (boiled eggs). These failures could place residents at risk of foodborne illness. The findings include: The following kitchen observation were made beginning on 03/21/23 at 9:30 AM and concluding at 10:15 AM: Observed two bags of boiled eggs dated 3/2 in the top shelf of the refrigerator. During an interview with the DM on 03/21/23 at 02:37 PM she stated the eggs could be stored in refrigerator for one month. During an interview with the DM on 03/22/23 at 09:50 AM she stated she had thrown the boiled eggs out because they can only be stored or 7 days. During an interview with the DM on 03/23/23 at 08:30 AM she stated perishable foods without an expiration date can only be stored for 7 days. She stated it is everyone's responsibility to monitor perishable foods stored…

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.