Johnson County Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to implement Enhanced Barrier Protection (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) for three out of three residents (Residents #5, #6, and #7) sampled for infection control with wounds. The facility census was 72 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient proof of the Registered Nurse (RN) eight consecutive hours a day coverage during the Fiscal Year (FY) Quarter Four 2024 Payroll Based Journal (PBJ- a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for all the dates triggered within the quarter equaling nine total days; during FY Quarter One 2025 PBJ for all the dates triggered within the quarter equaling two total days; during FY Quarter Two 2025 PBJ for all the dates triggered within the quarter equaling 18 total days; and during FY Quarter Three 2025 PBJ for all the dates triggered within the quarter equaling 45 total days. This deficient practice had the potential to affect all residents within the facility. The facility census was 75 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments and contents, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to have parameters listed in the medication orders for Acetaminophen (a widely used over-the-counter medication that relieves pain and reduces fever) containing medications for three sampled residents (Resident #1, #6, and #78) of out of 18 sampled residents. The facility census was 75 residents. Review of policy entitled Medication Management and Monitoring dated 2019 showed that it was the responsibility of nursing professionals was to be aware of action, correct dosage and route, frequency, and other considerations as required for the administration of medications.1. Review of Resident #78's admission Record showed the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure 10 Nurse Assistants (NA A, NA B, NA C, NA D, NA E, NA F, NA G, NA H, NA I, and NA J) out of 24 were not Certified Nursing Assistants (CNAs) within four months of hire. The facility census was 75 residents. A policy on NA training was requested but was not received from the facility. 1. Review of an undated hire record sheet showed:-NA A was hired on 2/6/25.-NA B was hired on 4/16/25.-NA C was hired on 3/17/25.-NA D was hired on 3/2/25.-NA E was hired on 6/11/24.-NA F was hired on 1/30/25.-NA G was hired on 2/27/24.-NA H was hired on 3/31/25.-NA I was hired on 1/3/25.-NA J was hired on 4/18/25. During an interview on 10/10/2025 at 2:23 P.M., NA A said:-He/She had started CNA class last week. -He/She was hired in February 2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure consistent and accurate wound assessments by a trained professional and failed to obtain a physician's order prior to treatment of an open wound for one sampled resident (Resident #2) out of 18 sampled residents. The facility census was 75 residents. Review of the facility's Skin Integrity Management policy, dated 2007 showed:-Ulcers and wounds will be assessed accurately to determine the wound or ulcer type.-Non-pressure ulcers will be assessed weekly. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete thorough and timely fall investigations and failed to update care plans for two sampled residents (Resident #3 and #19) who fell multiple times out of 18 sampled residents. The facility census was 75 residents. Review of the facility's undated policy titled Fall Policy and Procedure showed:-The purpose of the policy was to ensure appropriate medical and multi-disciplinary assessment of falls and fall risk factors; to coordinate management of acute and recurrent falls; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate care for one sampled resident (Resident #10) with a Gastrostomy (G-Tube- an opening into the stomach from the abdominal wall, made surgically for the introduction of food) out of 18 sampled residents. The facility census was 75 residents. Review of the facility's undated policy titled Tube Feeding Protocol showed:-The head of bed (HOB) would be elevated at least 30 degrees.-If at any time during the tube feedings the resident's HOB was lower than the 30 degrees, staff were to stop the tube feeding until the HOB was re-elevated to at least 30 degrees.1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate under five percent (%) for one sampled resident (Resident #69) out of 18 sampled residents. Two medication errors were detected out of 31 observed opportunities resulting in an error rate of 6.45%. This deficient practice had the ability to affect all residents. The facility census was 75 residents. Review of the facility's undated policy titled Crushing Medication Policy showed:-Medications that were not to be crushed may be opened and sprinkled into pudding or applesauce if clinically appropriate.-If medications were not able to be crushed or opened up, staff were to place them whole into a medication cup along with the crushed medication, then mixed together with pudding or applesauce. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week in the fourth quarter of the fiscal year for July 2023, August 2023, September 2023, in the first quarter of the fiscal year for October 2023, November 2023, December 2023 and in the second quarter of fiscal year for January 2024, February 2024, March 2024. The facility further failed to ensure the Director of Nursing (DON) was not serving as the charge nurse when the facility census was greater than 60 residents. This deficiency had the potential to affect all residents. The facility census was 69 residents. A facility RN staffing policy and procedure was requested and not received prior to exit. Review of the facility's Facility Assessment updated 8/2024 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionell, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak with accepted response protocols, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an antibiotic stewardship protocol/program and a system to monitor appropriate antibiotic use for residents. The facility census was 69 residents. Review of the facility's Antibiotic Stewardship policy dated 2018 showed: -The purpose of the policy included: --To apply the best practice into a system to monitor antibiotic use. --To implement protocols to ensure residents who require an antibiotic are prescribed the appropriate antibiotic. --To monitor the use of antibiotics. --To reduce the risk of adverse events, including development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use. -Apply the revised McGreer criteria for assessing for the suspected infections for Upper Respiratory Infections (URI), Urinary Tract Infections (UTI), or other infections. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate one or more individuals with the required primary professional training as the Infection Preventionist (IP) for the facility's Infection Prevention Control Program. The facility census was 69 residents. The facility did not provide a policy regarding required primary professional training for the IP. 1. During an interview on 8/22/24 at 9:22 A.M., the Director of Nursing (DON) said: -He/She was going to be the facility IP. -He/She had not taken any of the certification classes for the IP role at this time. During an interview on 8/22/24 at 9:38 A.M., the Administrator said: -He/She had the IP certificate and dedicated two to three hours per week for Infection Control duties. -His/Her degree was in Social Work. He/She did not have a degree in any of the approved primary professional medical trainings. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a policy and a physician's order that addressed the settings for a low air loss mattress (LAL - a mattress with an air pump designed to distribute the patient's body weight over a broad surface area to prevent and treat pressure wounds) for one sampled resident (Resident #25) with an unstageable (not stageable due to coverage with dead tissue) pressure ulcer, failed to complete weekly wound/skin assessments to include detailed descriptions of the wounds, measurements, and accurate staging of the pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) and failed to update the resident's care plan to reflect the current stage of the resident's pressure ulcer, out of 17 sampled residents. The facility census was 69 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to utilize a tube feeding policy that instructed licensed nursing staff regarding the current professional standard for verifying correct placement of gastrostomy (G-tube - surgical creation of a permanent opening into the stomach through the skin for the introduction of nourishment and fluids through a tube; also known as feeding tube) tubes failed to ensure and document measurement of the resident's feeding tube to ensure correct placement and to ensure the resident's physician's order was correct and that the resident's tube feeding infused in accordance with the physician's order for one sampled resident (Resident #1) out of 17 sampled residents. The facility census was 69 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide Trauma Informed Care (TIC - an approach to delivering care incorporating knowledge about trauma into care plans, policies, and practices to avoid re-traumatization) assessment and care planning for two sampled residents (Resident #18 and Resident #53) out of 17 sampled residents. Residents #18 and #53 were diagnosed with Post Traumatic Stress Disorder (PTSD - an anxiety disorder that can develop after a person experiences or witnesses a traumatic event. Symptoms of PTSD can include outbursts, disturbed sleep, distressing memories and thoughts about the event, and emotions such as fear, anger, guilt, and shame, which can be severe enough to interfere with one or more aspects of daily life). The facility census was 69 residents. Review of the facility's Trauma Informed Care policy, dated 2022 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician responded to the pharmacist's recommendation for gradual dose reduction (GDR) for psychotropic (relating to or denoting drugs that affect a person's mental state) medication in a timely manner for one sampled resident (Resident #22) out of 17 residents. The facility census was 69 residents. Review of the facility Pharmacy Services policy, undated showed: -A consultant pharmacist makes monthly visits. -The consultant pharmacist makes recommendations to the physician and to the facility about GDR. -The Director of Nursing (DON) reviews and implements the monthly consultant pharmacist's recommendations. -The physician is notified for GDR recommendations by the pharmacist. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing was posted correctly at the beginning of each shift including facility name, date, census, and total number and actual hours worked per shift which could have the potential to affect all residents in the facility. The facility census was 69 residents. A facility policy was requested for staff posting and was not received prior to exit. 1. Observation on 8/18/24 at 10:32 A.M., showed the daily staffing with required information on staff titles and total hours worked was not posted on second or third floor. Observation on 8/19/24 at 9:00 A.M., showed the daily staffing with required information on staff titles and total hours worked was not posted on second or third floor. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the nozzles of the dishwasher spray wand free of debris; to maintain the vent outlets of the climate control units in the kitchen free from a heavy dust buildup; to discard molded food from the walk-in refrigerator; to ensure two thermometers were calibrated (correlate the readings of (an instrument) with those of a standard in order to check the instrument's accuracy), to ensure the food warmer was cleaned prior to use for breakfast on 11/14/22; to have test strips to test the concentration of the sanitizing agent in the sanitizing sink; and to maintain the ice machines on the 2nd floor and in the dining room free of biofilm (the result of microorganisms attaching to a surface). The facility census was 75 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to include the following in its Water Management Plan: a diagram which showed which hot water heaters the water originated from and the destinations of water from those hot water heaters; plans for implementing testing protocols to ensure what corrective actions that the facility would implement as a result of changes in municipal or facility water quality; an assessment of where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility's water system; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Certified Nursing Assistants (CNA's) had a minimum of 12 hours of in-service education (which was required to include abuse/neglect and dementia cares) per year. This had the potential to affect all residents. The facility census was 75 residents. The policy regarding CNA training was requested and not received from the facility at the time of exit. 1. Record review of the facility's in-service records showed: -There were six in-services performed this year. -Dementia and abuse/neglect were not included. During an interview on 11/15/22 at 11:24 A.M., the Director of Nursing (DON) said the facility had not had any CNA in-services in a long time. During an interview on 11/15/22 at 11:25 A.M., the Administrator said: -The facility stopped doing in-services during the pandemic. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy curtains were clean for one sampled resident (Resident #25); failed to maintain the mattress in Resident #13's room in an easily cleanable condition and without cracks; failed to maintain the ceiling of the 3rd floor dining room free of a dust buildup; failed to maintain the fan in resident room [ROOM NUMBER] free of a dust buildup; failed to maintain the bed in resident room [ROOM NUMBER] in an easily cleanable condition; and failed to maintain a ceiling fan in the basement dining room free of a heavy dust buildup. The facility census was 75 residents. Record review of the facility's policies showed no reference to cleaning, laundering, or disinfecting residents' privacy curtains. 1. Record review of Resident #25's face sheet showed he/she was admitted to the facility with the following diagnoses: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the foods on the test tray after the residents on the third floor were served, maintained at or close to 120 ºF (degrees Fahrenheit) at the time of service. This practice potentially affected at least five residents who ate in the third floor dining room. The facility census was 75 residents. 1. Record review of Resident #57's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning) dated 10/14/22 showed he/she was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 10 out of 15. During an interview on 11/14/22 at 1:24 P.M., the resident said all three meals he/she received were cold. Observations on 11/14/22 showed: - At 1:29 P.M., three residents on the third floor received their meals Salisbury steak at 108 ºF. [...]

Inspectors wroteBased on observation and interview, the facility failed to prevent the existence of live roaches in the kitchen area. This practice affected the kitchen area. The facility census was 75 residents. 1. Observations on 11/14/22, showed the following: - At 9:30 A.M., one roach crawled around and under the table at the dishwasher area. - At 9:43 A.M. one dead roach was on the ground in the dry storage room next to the kitchen - At 9:52 A.M. one dead roach was observed behind table with seasoning bottles. - At 11:23 AM., one roach was seen on the phone table next to the Dietary Manager's (DM) office. During an interview on 11/14/22 at 1:47 P.M., the DM said roaches were an ongoing problem and the pest control company came every two weeks. [...]

Inspectors wroteBased on interview and record review, the facility failed to invite one sampled resident (Resident #41) to their quarterly care plan meetings out of 19 sampled residents. The facility census was 75 residents. 1. Record review of Resident #41's undated face sheet showed the resident admitted with the following diagnoses: -Altered Mental Status (AMS- a group of cognitive and physical symptoms that differ from the baseline mental status). -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood). -Personal History of Transient Ischemic Attack (TIA- temporary interference with blood supply to the brain) without deficits. Record review of the resident's Social Service's note dated 8/16/22 showed: -The resident did not speak a lot to anyone. -When he/she did it was often a low tone mumble. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a choice in scheduled meal times; to honor a resident's request for additional food after communicating he/she was still hungry; to provide snacks when requested; to assist the resident to move to a facility closer to his/her family for one sampled resident (Resident #38); and to provide an alternate food of similar nutritive value for one sampled resident (Resident #71) out of 19 sampled residents. The facility census was 75 residents. Record review of the facility's undated Dietary Services Policy showed if a resident refused food, an alternate of a similar nutritive value, consistent with the usual and ordinary food items provided to residents, should have been offered. 1a. Record review of Resident #38's face sheet showed he/she was admitted to the facility as his/her own responsible party. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from abuse/neglect or mistreatment while under supervision of the facility staff, resulting in a resident to resident altercation for two sampled residents (Resident #73 and #66), who both had potential reactive behaviors that were known by the facility, out of 19 sampled residents. The facility census was 75 residents. Record review of the facility's Abuse and Neglect policy dated reviewed in 2016 showed: -To ensure that resident's rights are respected and honored. -To ensure each resident is treated with dignity and care, free from abuse or neglect, to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an alleged resident to resident altercation to the state agency within the required time frame for two sampled residents (Resident #73 and #66), who had an alleged non-injury altercation, out of 19 sampled residents. The facility census was 75 residents. Record review of the facility's Abuse and Neglect policy dated reviewed in 2016 showed: -An resident to resident alteration or mistreatment was defined as a negative, often aggressive, interaction between residents in long term care communities. These incidents include but not limited to: physical, verbal and sexual abuse and are likely to cause emotional and or physical harm. Other examples of a resident to resident mistreatment include: roommate conflicts, invasion of privacy and personal space; and verbal threats and harassment. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation of a resident to resident altercation that showed the circumstances of the incident, what occurred, what the facility's response was, witness statements (including residents) and the facility's plan of action to prevent the recurrence for two sampled residents (Resident #73 and #66) out of 19 sampled residents. The facility census was 75 residents. Record review of the facility's Abuse and Neglect policy dated reviewed in 2016 showed: -To ensure each resident is treated with dignity and care, free from abuse or neglect, to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. -An resident to resident alteration or mistreatment was defined as a negative, often aggressive, interaction between residents in long term care communities. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan that met the medical, nursing, mental, and psychosocial needs by addressing major depressive disorder (a common and serious medical illness that negatively affects how you feel, the way you think and how you act) for one sampled resident (Resident #41) out of 19 sampled residents. The facility census was 75 residents. Record review of the facility's policy titled Policy for Care Plan dated 2014 showed: -The care plan shall be comprehensively communicated to all care staff that addresses short-term problem/services and long-term problem/services. [...]

Inspectors wroteBased on interview and record review, the facility failed to include any direct care staff, the resident, and/or the resident's representative when developing a comprehensive care plan for one sampled resident (Resident #38) out of 19 sampled residents. The facility census was 75 residents. Record review of the facility's policy titled Policy for Care Plan dated 2014 showed: -Care plans were to be developed with input from an interdisciplinary team (IDT) as well as the resident/family. -Care plans will be reviewed and updated every three months during care plan meetings with input from all care plan team members. 1. Record review of Resident #38's face sheet showed he/she was admitted to the facility as his/her own responsible party with diagnoses of: -Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide one sampled resident (Resident #41) with proper Activities of Daily Living (ADL) care necessary to maintain grooming and care plan the procedures necessary to carry out grooming care out of 19 sampled residents. The facility census was 75 residents. 1. Record review of Resident #41's undated face sheet showed the resident admitted on [DATE] with the following diagnoses: -Personal History of Transient Ischemic Attack (TIA- temporary interference with blood supply to the brain) without deficits. -Essential (Primary) Hypertension (HTN-high blood pressure). Record review of the resident's care plan dated 11/9/22 showed: -The resident was fully dependent on care staff for personal hygiene and oral care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately document medication administration and any refusal of medication; to notify the resident's physician of ongoing refusal of medication and document notification with outcome for one sampled resident (Resident #57) out 19 sampled residents. The facility census of 75 residents. 1. Record review of Resident #57's admission Face-sheet showed he/she had the following diagnosis: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) with behaviors. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow-up with recommendations from a hearing exam, to include a return appointment for hearing aids for one sampled resident (Resident #40) out of 19 sampled residents. The facility census was 75 residents. A policy related to follow-up of outside appointments was requested and not provided at the time of exit. 1. Record review of Resident #40's admission Face Sheet showed he/she was his/her own responsible person. Record review the resident's Audiology Visit Summary Report dated 2/24/22 at 10:20 A.M. showed: -The resident was referred to the hearing clinic by the facility due to decreased hearing. -The resident had a hearing exam on 2/24/22. -The resident had profound hearing loss in the right ear and moderate/severe hearing loss in left ear. -The resident staid he/she would be getting a hearing aid elsewhere. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician's order for oxygen was transcribed to the resident's physician's order sheet and to ensure oxygen nasal cannula (a device used to deliver supplemental oxygen through a plastic tube into the nose in a sanitary manner) and tubing was stored to prevent contamination when not in use for one sampled resident (Resident #42) out of 19 sampled residents. The facility census was 75 residents. 1. Record review of Resident #42's Face Sheet showed he/she was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing), seasonal allergies, high cholesterol and arthritis. Record review of the resident's Care Plan updated 7/25/22 showed the resident received oxygen at 2 liters per minute. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified of an acute behavior, to document the facility intervention for one to one behavioral monitoring, to ensure timely follow up to behavioral health services was provided and to develop care plan interventions, to include a detailed suicide intervention plan, for one sampled resident (Resident #21) who had a history of verbalizing suicidal ideations and had expressed a suicidal ideation, out of 19 sampled residents. The facility census was 75 residents. Record review of the facility policies and procedures showed there was no policy and procedure for behaviors related to suicidal Ideation. The facility provided an undated Suicidal Ideation Screening form that showed screening questions to indicate whether a further more detailed assessment was indicated. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to adequately assess, monitor, reevaluate and document ongoing verbally aggressive behaviors; and failed to implement and document a behavioral safety plan in response to increased aggressive behavioral reactions for one sampled resident (Resident #57) who had a history of inappropriate behavioral actions (barricade bedroom door), being verbally aggressive, and making threats of harm toward facility staff, out 19 sampled residents. The facility census of 75 residents. A behavior policy was requested and was not provided by the time of exit. 1. Record review of Resident #57's admission Face-sheet showed he/she had the following diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate social services were implemented upon admission when a history of depression and suicidal ideation was known; to provide acute interventions after an acute behavior and requested counseling services for one sampled resident (Resident #21); and to provide assistance with or make arrangements for a transfer to another facility for one sampled resident (Resident #38) out of 19 sampled residents. The facility census was 75 residents. Record review of the facility's undated policy titled Discharge and Transfer Resident showed: -Residents were to be assessed for discharge potentials at admission, quarterly, and when a verbal request was made by a resident. -Residents were to be interviewed quarterly, at a minimum, to assess discharge wishes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's diet orders were followed for one sampled resident (Resident #52) with a diagnosis of dysphagia (difficulty swallowing) and orders for a mechanical soft diet (a diet designed for people who have trouble chewing and swallowing; chopped, ground foods are included in this diet, as well as foods that break apart without a knife) out of 19 sampled residents; and failed to follow the recipe for pureed (cooked food, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) Salisbury steak and pureed cabbage and carrots to ensure those items had the consistency of creamy paste or liquid. This practice potentially affected at least six residents with pureed diets. The facility census was 75 residents. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed accommodate residents' food preferences; and to offer appealing options of similar nutritive value to residents who chose not to eat the food that was initially served or requested a different meal choice for two sampled residents (Resident #38 and #17) out of 19 sampled residents. The facility census was 75 residents. Record review of the facility's undated Dietary Services Policy showed if a resident refused food, an alternate of a similar nutritive value, consistent with the usual and ordinary food items provided to residents, should have been offered. 1. Record review of Resident #38's face sheet showed he/she was admitted to the facility as his/her own responsible party. [...]