Mayo Healthcare Inc.

Based upon interview and record review, the facility failed to ensure that the director of food and nutrition services meets minimum qualification if a qualified dietitian is not employed full-time. Findings include:Per interview with the Dietary Manager on 5/12/26 at 10:30 AM, she stated she has been in the position for 6 months and confirmed she is not certified as a dietary or food service manager and does not meet the educational and experience requirements in the absence of a certification.Per interview with the facility dietician on 5/12/26 at 10:30 AM, she stated she does not work full time. Per record review of the Head Chef/Kitchen Manager job description, as of 5/13/26, it states that qualifications for the position include a dietary manager certification.Per interview with the Administrator on 5/12/26 at 12:30 PM, she confirmed the dietician is not full-time at the facility and that the dietary manager does not meet the certification, education or experience requirements to serve as a dietary manager.

Based on observation and interview, it was determined that the facility failed to store food in accordance with professional standards for food service safety and failed to maintain a sanitary kitchen. Findings include: Per observation of the kitchen on 5/5/25 at 6:20 AM, the floor was observed to be coated with a sticky substance. There was a food serving station that had dried peas and onions on it. Per observation of the walk-in freezer on 5/5/25 at approximately 6:30 AM, a container of frozen pesto was dated to be used by 4/28/25. Per observation of the walk-in refrigerator there was a bag of pepperoni that had a use by date of 5/4/25. There was a bowl of chocolate pudding that had an expiration date of 5/4/25. There was a hot dog placed on a plate that had an expiration date of 5/3/25. Per observation of dry kitchen area there was a bowl of granola that had an expiration date of 4/25/25. There was a bowl of chocolate chips with a use by date of 4/30/25. An interview was conducted with Kitchen Staff Member #1 on 5/5/25 at 6:46 AM. Kitchen Staff Member #1 confirmed these items…

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 meet the requirement for Payroll Based Journal (PBJ) data submission for the first quarter of the facility's fiscal year 2025, October-December 2024. Findings include: Per record review of the PBJ Data Report for the first quarter of the fiscal year 2025 provided by Centers for Medicare & Medicaid Services (CMS), the report identifies areas of concern specific to the facility. The concerns reported for the first quarter of the 2025 fiscal year were: failure to submit data for the first quarter, a one-star rating for staffing, excessively low weekend staffing, no registered nurse hours, and failure to have Licensed Nursing Coverage 24 Hours/Day. During an interview on 5/7/25 at 10:03 AM with the facility Administrator and the Director of Nursing, it was confirmed that the Payroll Based Journal data was not submitted for the first quarter of the facility's fiscal year. The facility was made aware of the error in February 2025 when they discovered, online, that their Nurse rating had dropped to one and that facility's PBJ 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 Per observation, interview, and record review, the facility failed to maintain an Infection, Prevention, and Control Program (IPCP) that reduces the risk of Residents contracting communicable diseases to the greatest extent possible as evidenced by an IPCP that is not updated annually, a lack of transmission-based precaution signage, and a lack of a water management program for Legionella. Findings include: 1. Per review of the provided IPCP polices and procedures, all policies and procedures had a last revised date in the year 2022. Per interview on 3/13/24 at approximately 12:00 PM, the Administrator confirmed that the facility's IPCP has not been reviewed or updated within the last year as required. 2. Per observation on 3/12/24 at approximately 11:00 AM, there was a Personal Protective Equipment (PPE) cart outside of Resident #3's room. A sign on the door said check with nurse prior to entering and another sign said wash hands with soap and water. A housekeeper inside the resident room is wearing PPE (gown,…

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.

3. Per an interview on 3/12/23 at approximately 9:00 AM, Resident #17's family indicated Resident# 17 had been refusing food and medications for several days. The decision was made to start end-of-life care. The family did not want complete Hospice care; rather, they felt the facility could provide adequate pain control and allow the family to be present. The resident was moved to a designated space that the facility provided for end-of-life care. Per record review, Resident #17 has a diagnosis of Alzheimer's Dementia and chronic pain related to spinal stenosis (when the space inside the backbone is too small, putting pressure on the spinal cord and nerves that travel through the spine). A progress note written by the Nurse Practitioner (NP) on 3/4/24 reveals a discussion with Resident 17's family regarding the recent decline and the family's decision to move Resident #17 to end-of-life care. A record review of Resident#17's care plan reveals no evidence of a comprehensive care plan developed specifically for end-of-life care. Per an interview on 3/12/24 at approximately 1:30 PM…

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 staff interview and record review, the facility failed to ensure that every resident is seen by a provider, who assesses the residents' total program of care, once every 30 days for the first 90 days after admission and then every 60 days thereafter for 6 of 25 sampled residents (Residents #28, #38, #30, #31, #29, and #22). Findings include: 1. Per record review, Resident #28 was admitted on [DATE]. Records of physician visits, during which they assessed the Resident's total program of care, were found for the dates of 9/29/23 and 3/10/24. A Nurse Practitioner note is also present with a date of 1/2/24. There were no other physician visit notes of this type in Resident #28's record. Per interview on 3/12/24 at approximately 1:45 PM, The Unit Manager confirmed that there were not enough provider visit notes in Resident #28's chart to meet the regulation. 2. Per record review, Resident #38 was admitted on [DATE]. No physician notes that contained a review of the total program of care could be located in…

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

Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals are stored and labeled according to accepted professional principles for expiration dates. Findings include: 1. Per observation of medications stored in the Turkey Hill Medication cart on 3/11/24 at approximately 2:00 PM, the following products were found with expiration date concerns: - A Lantus Solostar long-acting insulin pen for a resident was opened with no date of opening specified on the pen or pen bag. The insulin pen was not full and had been used for an undetermined number of days. The manufacturer specifies that the remaining insulin be discarded 28 days after opening. - A bottle of Latanoprost eye drops for a resident was opened with no date of opening specified on the bottle or the packaging. The packaging from the manufacturer specified that the remaining solution was to be discarded within 60 days of opening. - A bottle of Deep Sea Nasal Spray for a resident was labeled with an expiration date of 1/11/2024 per the manufacturer. - A bottle of Aspirin 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 record reviews and interviews, the facility failed to clarify code status and review care plan instructions and determine if the resident wishes to change or continue these instructions related to Advanced Directives, for 1 of 25 Residents in the sample. (Resident #15). Findings include: Per a record review, Resident #15 has resided at the facility since 12/13/2016 with the following diagnoses: Hemiplegia and Hemiparesis (A severe or complete loss of strength or paralysis on one side of the body) following a cerebral infarction (a stroke) and Dysphagia (Difficulty swallowing) related to the cerebral infarction. Another record review indicates a COLST (clinician orders for life-sustaining treatment) form that is dated 2/13/24 and signed by the Nurse Practitioner (NP) and Resident# 15's Power of Attorney (POA). The form indicates that the resident should be resuscitated, including chest compression, intubation, mechanical ventilation, defibrillation, and transfer to the hospital. Another 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interview and record review, the facility failed to develop a discharge care plan to identify goals and needs prior to discharge for 1 resident [Res.#40] of 4 residents reviewed. Findings include: Per review of Physician notes dated 12/5/23, Res. #40 was admitted to Mayo initially after a fall and femur fracture in September. [S/he] was discharged home in early November. A few days later [s/he] had a fall and went back to the Emergency Department. Res. #40 was admitted back to Mayo on 11/17/23, where the physician noted Res.#40 is making some progress with physical therapy and plan is to return home. Review of Res.#40's medical record after their admission on [DATE] reveals no documentation involving the resident and/or a resident representative in the development of the discharge plan. Review of Res.#40's Care Plan reveals no mention of discharge or that the discharge needs of the resident were identified and the resident or representative informed of a final plan. Per review of Res. #40's medical…

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 staff interviews and record review, the facility failed to ensure 2 of 2 applicable residents (Residents #1 & #2) were treated with respect and dignity. Findings include: Per record review and confirmed via interview, a Licensed Nursing Aide (LNA) verbally abused Residents #1 & #2 on 10/17/23. Per review of the facility's own investigation and confirmed by witness statements, a LNA told Resident #1 to shut up and called Resident #2 a fool. These incidents were done while other staff members were present, and the remarks were heard by these staff members. Staff did intervene by speaking with the offending LNA and telling them this was inappropriate behavior. It is not known if the residents heard these remarks, but because of their cognitive status, they could not recall the incident. Both residents remain at their baseline, with no negative outcomes. When the LNA was interviewed by the Administrator, the LNA denied saying shut up but did confirm that s/he called the resident a fool after the resident called them a fool. However, they said it was done so in a joking manner…

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.