Valley Manor and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to maintain the highest practicable physical wellbeing of the residents when no annual training records were found for, Nurse Aide (NA) A, Certified Nurse Aide (CNA) A and CNA C, when staff failed to adhere to proper infection control practices and when the facility did not have an a infection surveillance program. The facility census was 67. The facility did not provide the requested policy on education or of staff competencies. Review of the facility's Personal Protective Equipment - Using Gloves policy, dated September 2010, showed:-Gloves are used to prevent the spread of infections;-Gloves are used to protect wounds from contamination;-Gloves are used to protect hands from infectious material; [...]

Inspectors wroteBased on observation and interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety when facility staff failed to observe proper handwashing and hairnet procedures in the kitchen, routinely sanitize food surfaces, or maintain kitchen cleanliness standards, failed to properly monitor food storage temperatures, failed to present food that was attractive on the plate, and additionally failed to properly store and monitor food items for expiration dates. This had the potential to affect all residents in the facility. The facility census was 67. [...]

Inspectors wroteBased on interview and record review the facility failed to make a good faith attempt at utilizing the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents, when the facility did not monitor and review performance improvement plans (PIPs) for 2025 regarding resident pressure ulcers, resident snacks, and medication administration. This had the potential to affect all residents. The facility census was 67. [...]

Inspectors wroteBased on interview and record review the facility failed to prioritize its improvement activities; measure the success of actions, track performance; regularly review, analyze, and act on data collected regarding the facilities performance improvement plan. The facility census was 67. Review of the facilities Quality Assurance and Performance Improvement (QAPI) Program policy, dated February 2020, showed:-This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents;-The objectives of the QAPI program are to: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that an effective training program for all new and existing staff was in place, when the facility failed to complete a facility assessment to include: Staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population. Furthermore, the facility failed to track attendance and hours of training for staff members who required at least 12 hours of education yearly. The facility census was 67. The facility did not provide a policy on education or of staff competencies. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance of the risks and benefits of proposed care, when the facility failed to obtain written consent before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for three (Resident #5, Resident #9, and Resident #30) of the 17 sampled residents. The facility census was 67. No policies were provided by the facility related to obtaining consent for psychotropic medications. 1. Review of Resident #9's Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 12/2/25, showed: - Cognition was not intact; - The resident took anti-anxiety and anti-depressant medication; [...]

Inspectors wroteBased on interview and record review, the facility failed to create an environment respectful of the rights of a resident to make choices about significant aspects of his/her life, when the facility did not provide a means for one resident (Resident #19) to attend Saturday church services in accordance with their religious preferences and additionally failed to post a list of food substitutes for each meal for three residents (Residents #30, #40, and #60). This affected four of 17 residents sampled. The facility census was 67. Review of facility policy, Activity Programs, revised June 2018, showed:- Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident; [...]

Inspectors wroteDuring an interview and record review, the facility failed to maintain a surety bond that was equal or greater than one and one-half times the average monthly balance for the residents' personal funds for the last 12 consecutive months from December 2024 through November 2025. The facility census was 67. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow facility policy and investigate a bruise of unknown origin for one resident (Resident #44) and failed to investigate an allegation of physical abuse, when one resident, (Resident #30) reported to the nurse a facility staff member had struck him/her on the leg with a wheelchair intentionally. This affected two of the 12 residents sampled. The facility census was 67. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident care plans were created accurately for two of 17 sampled residents (Resident #10 and Resident #59) when the facility failed to address the use of a seatbelt on Resident #10's wheelchair and failed to address specific care needs, goals, and interventions for Resident #59. The facility census was 67. Review of the facilities Care Plans, Comprehensive Person Centered policy, dated March 2022, showed: - A comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed for each resident; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for three of 17 sampled residents (Resident #13, #30 and #67) when the facility did not include activity preferences for Resident #13, did not include fall interventions for Resident #67 and when the facility did not address behaviors for Resident #30. The facility census was 67. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when facility staff did not provide timely showers for three of 17 sampled residents (Resident #45, #56, and #59). The facility census was 67. Review of the facility policy, Shower/Tub bath, revised February 2018, showed:- The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin;- Documentation included: the date and time other shower/tub bath was performed; then name and title of the individual who assisted the resident with the shower/tub bath; all assessment data (e.g. any reddened areas, sores, etc. on the resident's skin) obtained during the shower/tub bath; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide an ongoing activities program for three of the 17 sampled residents (Resident #67, #8 and #13) when the facility staff failed to provide individualized and meaningful activities in accordance with the facility assessment and resident preferences. The facility census was 67. Review of the facility's Activity Programs policy, dated June 2018, showed:-The activities program is provided to support the wellbeing of residents and to encourage both independent and community interaction;-The activities program is ongoing and includes facility organized group activities, independent individual activities and assisted individual activities;-Individual and group activities are provided; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide proper respiratory care when staff failed to document the date when oxygen tubing was cleaned for three residents (Residents #10, #18, and #56 ) and additionally failed to properly store oxygen accessories at the bedside for one resident (Resident #56) resulting in possible exposure to bacteria during oxygen usage. This affected three of 17 sampled residents. The facility census was 67. No policies were provided by the facility related to oxygen tubing care or storage. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store drugs and biologicals in locked compartments under proper temperature controls when the facility failed to ensure refrigerator temperatures were accurately checked and recorded to ensure medications were being stored at a safe temperature. This had the potential to affect all residents who received refrigerated medication. The facility census was 67. Review of the facilities Medication Labeling and Storage policy, dated February 2023, showed: -The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light control; -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manor. 1. Observation of Medication room [ROOM NUMBER] on 12/16/25 at 10:11 A.M. showed: [...]

Inspectors wroteBased on observation, interview and record review, 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 and infections when, dietary staff did not change gloves between clean and dirty tasks and when facility staff did not apply Personal Protective Equipment (PPE) when they provided care and treatment for two residents (Resident #61 and Resident #46) and when the facility failed to have an infection surveillance program. The facility census was 67. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one of two sampled residents, Resident #28, identified with a pressure ulcer, received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing when the facility failed to properly follow physician's orders when performing wound care. The facility census was 67. No policies were provided by the facility related to wound care or pressure injuries. 1. Review of Resident #28's Quarterly MDS dated [DATE], showed:-No cognitive impairment;-Assistance of two staff for bed mobility and transfers;-At risk for pressure ulcers;-Pressure ulcer present on admit;-Diagnoses included diabetes, high blood pressure and anemia. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one nurse aide (NA) A completed a nurse aide training program within four months of his/her employment in the facility. The census was 67. The facility did not provide a policy regarding Nurse Aide training. Review of Nurse Aide (NA) A's employee file showed:-Date of hire 4/21/25; -No documentation that NA A had completed a nurse aide training program was found. During an interview on 12/15/24 at 10:11 A.M., NA A said:-He/She had not passed the knowledge part of the Certified Nurse Aide (CNA) test;-He/She worked as an NA only; -He/She was not sure when he/she would take the test again;-He/She was not aware he/she needed to be certified within 4 months of hire. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to honor one resident's religious preferences when the facility failed to offer a suitable substitute at the lunch meal service for Resident #19, who was assessed and documented as not being able to eat pork products. This affected one out of 12 sampled residents. The facility census was 67. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish an infection prevention and control program that included an antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) that included antibiotic use protocols and a system to monitor antibiotic use. The census was 67. Review of the facility Antibiotic Stewardship policy, dated December 2016 showed:- The purpose of antibiotic stewardship is to monitor the use of antibiotics in our residents and to include training, orientation, and education of staff with emphasize on the importance of antibiotics stewardship, and inappropriate use of antibiotics; - Antibiotics usage and outcome will be collected and documented using a facility-approved antibiotics surveillance tracking form; [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control to be responsible for the facility's Infection Prevention and Control Program. The census was 67. Review of the facility Components of Infection Control policy, undated, showed:- The Infection Preventionist is a person designated to serve as a coordinator of the infection prevention and control program;- Generally, it is best to have a registered nurse in this position;- Infection Preventionist must complete the required Centers for Disease Control (CDC) course on Infection Preventionist training. [...]

Inspectors wroteBased on interviews and record review, the facility failed to administer medications for pain management in accordance with the resident's physician orders, which caused unnecessary pain for one Resident (Resident #1) of five sampled residents. The facility census was 63. Review of the facility policy titled, Pain Assessment and Management, revised April 2025, showed: -Establish a treatment regimen specific to the resident based on consideration of the following: a) The resident's medical condition; b) Current medication regimen; c) Nature, severity, and cause of the pain. -The medication regimen is implemented as ordered; -Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications; -Contact the provider immediately if the resident's pain is not adequately controlled. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to maintain a clean and sanitary kitchen, did not ensure refrigerator and freezer temperatures were checked daily, did not ensure proper function of dishwasher by testing and logging it daily, did not use sanitizer solution on kitchen food preparation surfaces, did not keep food stored off the floor, did not ensure proper storage and labeling of foods, and when dietary staff did not wear hairnets prior to entering kitchen. The facility census was 68. 1. Review of facility policy, food receiving and storage, revised November 2022, showed: -Dry Food Storage: -Food in designated dry storage areas are kept at least 6 inches off the floor. -Refrigerated/Frozen storage: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to respect resident rights of four residents out of the 17 sampled residents, when the facility failed to provide grooming for one resident (Resident #10), failed to respond to call lights within a timely manner for one resident (Resident #22), and additionally failed to preserve the dignity of two residents, when the staff did not provide mouth care to a dependent resident, and did not keep bedside urinal away from one resident's drinks (Resident #34, and Resident #63) The facility census was 68. Review of the facility's Resident Rights Policy, undated., showed: - Residents have the right to a dignified existence, self determination, and communication with and access to persons and services inside and outside the facility. - Receive services and care outlined in the resident's care plan. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to consider the concerns and recommendations of the resident council members and failed to communicate with the council regarding their concerns as reported by seven of the eight residents who participated in a group meeting. This had the potential to affect all the residents. The facility census was 68. Review of the facility's policy for recording and investigating grievances/complaints, revised April, 2017 showed, in part: - All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievances; - Upon receiving a grievance and complaint report, the grievance and complaint report, the grievance officer will begin an investigation into the allegations; - The investigation and report will include: the date and time of the alleged incident; [...]

Inspectors wroteBased on record review and interview, the facility failed to hold residents' moneies separate from facility money when they did not reiumburse residents and/or their responsible partiies after the residents were discharged , which affected nine of 17 sampled residents. The facility census was 68. Facility did not provide a policy on refunds; Review of Resident Rights Policy, undated, showed: -Resident has a right to manage their financial affairs, including right to know , in advance, what charges a facility may impose against their personal funds; -If a resident chooses to deposit personal funds with facility, upon written autohrization of a resident, facility must act as a fiduciary of resident's funds and hold, safeguard, manage, and account for all personal funds. [...]

Inspectors wroteBased on interviews and record review, the facility failed to clarify the code status (whether the resident wished to have cardio-pulmonary resuscitation- CPR) of six of the 17 sampled residents, (Resident #22,#63,#6,#18,#29, and #33), and failed to ensure the appropriate code status was listed in the medical record and care planned correctly. The facility census was 68. Review of the facility's Advance Directive Policy dated April, 2013., showed: -Advance Directives will be respected in accordance with state law and facility policy. -The physician will provide an order for Do Not Resuscitate or Full Code. -The care plan will reflect the residents treatment preferences of their Advance Directive. -The Intradisciplinary team will review the Advance Directives ongoing reviews of each residents Advance Directive as needed and yearly. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide a safe, clean, comfortable and homelike environment for Resident #23, and common areas on the 200 & 300 halls. The facility census was 68. Review of the facility's undated Resident Rights Policy., included the resident has the right to live in a safe, clean, and homelike enviornment. 1. Review of Resident #23's 5 Day Medicare MDS (Minimum Data Set), a mandatory assessment completed by facility staff, completed on 5/17/24., showed: -The resident was re-admitted from hospital with infected hardware from hip repair; -History of Multi Drug Resistant Organisms; -Impaired Cognition; -Assistance with all Activities of daily living (ADL); -Diagnoses: [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents knew how to file a grievance. This affected any resident wanting to file a grievance. The facility census was 68. Review of the undated resident rights, showed, in part: - Federal regulations guarantee residents certain rights and the facility must meet these requirements; - Regular in-services should include education about resident rights; - Resident has the right to voice grievances to facility or other agency that hears grievances without discrimination of reprisal and without fear of discrimination or reprisal; - Resident has the right to and the facility must make prompt efforts by the facility to resolve grievances resident may have, in accordance with this paragraph; - Facility must make information on how to file a grievance or complaint available to the resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop individualized person centered comprehensive care plans for three of 17 sampled (Resident #18, #43, and #34) when shower preferences (Resident #18), shaving and nail care preferences (Resident #43), comfort care measures (Resident #34), oral care (Resident #34), risk for skin integrity (Resident #34), repositioning of resident (Resident #34) , and therapeutic activities and psychosocial needs (Resident #34) were not care planned. The facility census was 68. Review of facility policy, Care Plans Comprehensive Person-Centered, revised March 2022, showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff followed professional standards when staff failed to administer eye drops correctly which affected one of the 17 sampled residents, (Resident #26), failed to administer the correct dose of Tylenol (used to treat minor pain) for Resident #, failed to administer Flonase nasal spray (used to treat seasonal allergies) for Resident #21, and failed to allow the fingertip to air dry before obtaining the blood sugar for Resident #4 and #41. Additionally the staff failed to obtain a physician's order to obtain blood sugars for Resident #4. The facility census was 68. The facility did not provide a policy for administration of nasal sprays. Review of the manufacturer's guidelines for Flonase nasal spray, revised March 2016, showed, in part: - Blow your nose to clear your nostrils; - Close one nostril. [...]

Inspectors wroteBased ob observations, interviews, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care, which affected three of the 17 sampled residents, (Resident #18, #22 and #25), failed to provide AM care for Resident #25, and failed to ensure showers were completed for for Resident #10, #18, #29 and #43. Additionally, the facility failed to ensure shaving was completed for Resident #29 and #43. The facility census was 68. Review of the facility's policy for shower/tub bath, revised February, 2018, showed, in part: - The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin; - Documentation included: [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when staff failed to lock residents' wheelchairs during transfers (Resident #31), failed to close base of legs during transfer (Resident #31), transfering resident in a hoyer with only one staff present (Resident #6) and staff locked brakes of lift (Resident #25) which affected three of 17 sampled residents, (Resident #31, #6 and #25). The facility census was 68. Review of facility policy, Lifting Machine, Using a Mechanical, dated July 2017, showed: -At least 2 nursing assistants are needed to safely move a resident with a mechanical lift. -Make sure lift is stable and locked. -Make sure all necessary equipment (slings, hooks, chiains, straps, and supports) are on hand and in good condition. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff maintained the hydration status for five of the 17 sampled residents, (Resident #1, #10, #25, #58 and #63), when staff did not pass fresh ice water to the residents or offer thickened fluids to residents on special diets during the day or overnight hours. The facility census was 68. Review of the facility's policy for Resident Hydration and Prevention of Dehydration, dated October 2017 showed, in part: - The purpose is to ensure each resident maintains, to the extent possible, acceptable parameters of nutritional and hydration status and the facility provides nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to discard expired medications and biologicals stored within the medication room. The facility census was 68. The facility's undated policy for storage of medications showed it did not address expired medications. Observation and interview on 7/9/24 at 10:06 A.M., of the central supply cabinet showed: - Unopened bottle of Calcium 600 milligrams (mg.) with Vitamin D (supplement), expired 6/24; - Unopened bottle of Zinc Sulfate 220 mg., for dietary supplement, expired 3/24; - A box of Bisacodyl Suppositories used for constipation, expired 11/22; - The Assistant Director of Nursing (ADON) said he/she thought Certified Medication Technician (CMT) C checked for expired medications. The expired medications should be destroyed and not used. During an interview on 7/10/24 at 12:50 P.M., the Administrator said: [...]

Inspectors wroteBased on observation and interview the facility failed to ensure meals were served to meet the needs of the residents when staff failed to prepare food according to the registered dietician approved recipes, failed to follow dietary preferences, and failed to post a list of available menu substitutions for residents. This deficient practice affected five of seventeen sampled residents, (Resident #22, #21, #48, #31 and #32) The facility census was 68. The facility did not provide a policy on menus and nutritional adequacy. 1. Review of Resident #22's Quarterly Minimum Data Set, (MDS, a federally mandated assessment completed by the facility staff), dated 5/28/24 showed: - Cognitive skills intact; - Upper extremity impaired on one side; - Lower extremity impaired on both sides; - He/She required set up assistance for meals; - Diagnoses included: [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot food was not served at an appetizing temperature and burnt food was served to 10 of 17 sampled residents (Resident #21, #48, #35, #10, #27, #32, #41, #43, #3, and #32) The facility had a census of 68. Review of facility policy, food safety requirements, dated 9/1/21, showed: -Food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety. -When preparing food, staff shall take precautions in critical control points in food preparation process to prevent, reduce, or eliminate potential hazards. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure infection prevention measures where followed when the facility staff failed to place three residents on enhanced barrier precautions ( Residents #63, #34, and #23) and failed to maintain proper infection prevention practices when providing care for resident with a urinary catheter (Resident #58) out of the 17 sampled residents. The facility census was 68. Review of the facility's Infection Control Compliance Policy, dated August 2019., showed: - Routine monitoring and surveillance of the workplace are conducted to determine compliance with infection prevention and control policies and procedures. - The infection preventionist or designee will monitor the compliance and effectivness of the infection prevention and control practices. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish an infection prevention and control program that included an antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 68. The revised facility Antibiotic Stewardship policy,dated December 2016 showed in part: The purpose of antibiotic stewardship is to monitor the use of antibiotics in our residents and to include training, orientation, and education of staff with emphasize on the importance of antibiotics stewardship, and inappropriate use of antibiotics. Antibiotics usage and outcome will be collected and documented using a facility-approved antibiotics surveillance tracking form. [...]

Inspectors wroteBased on observation interviews, and record review, the facility failed to serve meals according to scheduled meal times. This affected one of 17 sampled residents . This had to potential to impact all residents in the community. The facility census was 68. Review of facility policy, food safety requirements, dated 9/1/21, showed: -Foods will be stored, prepared, distributed, and served in accordance with professional standards of food service safety; -Food and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of danger zone; -Timely distribution of all meals/snacks. Observation of posted meal times showed: -Dining served in dining room [ROOM NUMBER]:00 A.M., hall trays 9:00 A.M.; -Lunch served in dining room [ROOM NUMBER]:00 P.M., hall trays 1:00 P.M.; [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents received services with reasonable accommadtion of the residents' rights and preferences when staff did not honor four of 15 sampled residents, (Resident #6, #8, #11, and #15) preferences for having at least two showers a week and failed to ensure staff provided bedtime snacks for four sampled residents (Residents #8, #11, #15, and #48). The facility census was 60. Review of the facility's policy for bathing and showering, revised February 2018, showed, in part, the purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation included: - The date and time the shower/tub bath was performed, the name and title of the individual who assisted the resident with the shower; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff administered medications with a medication rate of less than 5%. Facility staff made four medication errors out of 28 opportunities for error, a medication error rate of 14.29%, which affected two of 15 sampled residents, (Resident #41 and #52). The facility census was 60. Review of the facility's policy for administering medications, revised April 2019, showed, in part: - Medications are administered in a safe and timely manner, and as prescribed; - Medications are administered in accordance with prescriber orders, including any required time frame. Review of the facility's policy for instillation of eye drops, revised January 2014, showed, in part: - The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes; [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure they prepared food under sanitary conditions when they failed to keep food labeled, dated, and sealed. The facility census was 60. Review of Labeling and Dating Foods (Date Marking) dated 2016 showed: -Date marking for dry storage food items o Once a case is opened, the individual food items from the case are dated. -Date marking for refrigerated storage food items o Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and placed in/on the proper storage location utilizing the first in -first out method of rotation; o Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturers expiration date; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff treated residents in a manner that maintained their dignity when staff stood to assist residents to eat which affected three of 15 sampled residents, (Resident #26, #27 and #261). The facility census was 60. Review of the facility's policy for dignity, revised February 2021, showed, in part: - Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; - Residents are treated with dignity and respect at all times; - The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's facility stay; [...]

Inspectors wroteBased on record review and interviews, the facility failed to notify the resident or responsible party when a resident's money reaches $200 within the Supplemental Security Income (SSI) (program provides monthly payments to adults and children with a disability or blindness who have income and resources below specific financial limits. SSI payments are also made to people age [AGE] and older without disabilities who meet the financial qualifications.) resource limit ($5,301.85) in the resident trust account. This affected one resident who the facility held funds for (Resident #6). The census was 60. Review of the Resident Trust Fund Management policy dated December 2021 showed: - The facility resident funds are to be maintained in a bank checking account used exclusively for those funds. [...]