Inspection Reports for
The Wheatlands Health Care Center

750 W WASHINGTON ST, KINGMAN, KS, 67068-2000

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Deficiencies (last 8 years)

Deficiencies (over 8 years) 7.1 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

18% worse than Kansas average
Kansas average: 6 deficiencies/year

Deficiencies per year

20 15 10 5 0
2012
2013
2014
2015
2016
2021
2023
2024

Occupancy

Latest occupancy rate 83% occupied

Based on a December 2024 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Occupancy rate over time

20% 40% 60% 80% 100% Aug 2012 Dec 2013 Sep 2016 Jun 2021 Dec 2024

Inspection Report

Routine
Census: 45 Deficiencies: 6 Date: Dec 4, 2024

Visit Reason
Routine inspection of The Wheatlands Health Care Center to assess compliance with regulatory standards related to resident dignity, pressure ulcer care, fall prevention, medication safety, food safety, and infection control.

Findings
The facility failed to protect resident dignity, provide appropriate pressure ulcer care, implement effective fall prevention, ensure medication storage security, maintain sanitary food storage, and uphold infection control practices. Multiple residents were affected by these deficiencies, with potential for harm.

Deficiencies (6)
F 0550: The facility failed to protect the privacy and dignity of Resident 24 when staff observed her partially dressed in her room with the door open and did not intervene to close the door or provide privacy.
F 0686: The facility failed to provide appropriate pressure ulcer care for Resident 9, including failure to use a pressure reducing device and use of an incorrect size full body sling for mechanical lifts.
F 0689: The facility failed to maintain a safe environment by not using the appropriate size full body lift sling for Resident 9, not applying foot pedals on Resident 1's wheelchair, and leaving Resident 26 unattended attached to a mechanical lift, resulting in a fall.
F 0761: The facility failed to ensure medication storage room door remained closed and secured, exposing seven cognitively impaired residents to potential accidental ingestion of medications.
F 0812: The facility failed to store, prepare, and serve food in a sanitary manner, including storing food items on the floor, expired items, and unlabeled frozen foods, risking food-borne illness.
F 0880: The facility failed to implement an effective infection prevention and control program, including failure to perform hand hygiene between resident contacts, improper catheter and wound care, and improper storage and changing of oxygen tubing.
Report Facts
Residents affected: 45 Residents sampled: 12 Resident weight: 154 Wound measurements: 2 Wound measurements: 1.5 Wound measurements: 0.2 Wound measurements: 3 Wound measurements: 0.5

Employees mentioned
NameTitleContext
Administrative Nurse BAdministrative NurseConfirmed dignity concerns and medication storage issues
Certified Nurse Aide SCertified Nurse AideObserved using incorrect sling size and reported staff practices
Certified Medication Aide CCCertified Medication AideObserved using incorrect sling size and catheter care deficiencies
Licensed Nurse RLicensed NurseObserved wound care deficiencies and confirmed infection control lapses
Dietary Manager CDietary ManagerReported food storage and labeling deficiencies
Laundry Aide JLaundry AideObserved failing to perform hand hygiene between resident rooms
Administrative Nurse GAdministrative NurseConfirmed infection control expectations and catheter care standards

Inspection Report

Routine
Census: 50 Deficiencies: 2 Date: Jan 19, 2023

Visit Reason
Routine inspection to assess compliance with sanitation, infection control, and proper disposal of garbage and refuse at the nursing home.

Findings
The facility failed to properly maintain and dispose of kitchen garbage and refuse, with dumpsters left open and overflowing. Additionally, housekeeping staff lacked knowledge of the required contact wet times for disinfectants used, risking inadequate infection control.

Deficiencies (2)
F0814: The facility failed to maintain and dispose of kitchen garbage and refuse properly, with dumpsters left open and lids unable to close. The facility lacked a policy for garbage disposal and failed to maintain the dumpster area in a sanitary condition.
F0880: The facility failed to ensure a clean, sanitary environment due to housekeeping staff not knowing the manufacturer's contact wet times for disinfectants used in resident rooms. This failure had the potential to affect all resident areas.
Report Facts
Resident census: 50

Employees mentioned
NameTitleContext
Dietary Staff AA mentioned in relation to garbage disposal findings
Housekeeping staff U mentioned in relation to disinfectant use and knowledge
Housekeeping staff V mentioned in relation to disinfectant use and knowledge
Administrative staff AReported housekeeping staff should be educated on proper cleaner use

Inspection Report

Routine
Census: 41 Deficiencies: 3 Date: Jun 17, 2021

Visit Reason
Routine inspection of The Wheatlands Health Care Center to assess compliance with professional standards of care, medication administration, food safety, and other regulatory requirements.

Findings
The facility failed to provide appropriate respiratory care by not changing and dating oxygen humidifier bottles and tubing. It also failed to administer sliding scale insulin as ordered for elevated blood sugars and did not store food safely by failing to date, reseal, and discard expired food items.

Deficiencies (3)
F 0695: The facility failed to provide respiratory care consistent with professional standards by not changing and dating the humidifier bottle and tubing for oxygen therapy for Resident 24.
F 0757: The facility failed to ensure Resident 12 received sliding scale insulin as ordered for blood sugars above 250 mg/dL.
F 0812: The facility failed to store foods safely by not dating open items, not resealing opened food, and failing to discard expired food items in the main kitchen.
Report Facts
Residents reviewed: 12 Residents reviewed for unnecessary medications: 5 Blood sugar readings above 250 mg/dL without sliding scale insulin: 11 Expired food items: 41

Inspection Report

Follow-Up
Deficiencies: 1 Date: Sep 29, 2016

Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.

Findings
The report documents that the previously cited deficiencies have been corrected as of the revisit date. Specific corrections are identified by regulation or Life Safety Code provision numbers.

Deficiencies (1)
Regulation 28-39-256 deficiency was corrected and completed by 09/29/2016.

Inspection Report

Follow-Up
Deficiencies: 1 Date: Sep 26, 2016

Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

Findings
The revisit confirmed that the deficiency identified under regulation 483.35(i) was corrected as of 09/26/2016. No other deficiencies or uncorrected issues were noted.

Deficiencies (1)
Regulation 483.35(i) deficiency was corrected as of 09/26/2016.

Inspection Report

Plan of Correction
Deficiencies: 1 Date: Sep 15, 2016

Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report dated September 15, 2016.

Findings
The Plan of Correction addresses a deficiency related to water temperature control, specifying training for housekeeping, maintenance, and residential living employees and implementation of a monthly water temperature monitoring log.

Deficiencies (1)
Tag S3420-E: Employees were trained on the requirement that water temperature be at 120 degrees or below. A maintenance water temperature log was created and temperatures will be taken monthly in random areas of the facility.

Employees mentioned
NameTitleContext
Sharon RinkeAdministratorAdministrator submitting the Plan of Correction.
Shirley BoltzContact person for Plan of Correction assistance.

Inspection Report

Re-Inspection
Census: 16 Deficiencies: 1 Date: Sep 15, 2016

Visit Reason
This visit was an Assisted Living/Residential Healthcare Licensure Resurvey to assess compliance with mechanical requirements and other regulations.

Findings
The facility failed to ensure that hot water temperatures in the assisted living apartments did not exceed 120 degrees Fahrenheit, with multiple sinks measuring temperatures above this limit. Maintenance staff reported lack of water temperature check logs and no policy for checking water temperatures in assisted living.

Deficiencies (1)
KAR-28-29-256 (c)(2)(B): The facility failed to ensure hot water temperatures in assisted living apartments did not exceed 120 degrees Fahrenheit, with multiple resident sinks measuring between 122.5 and 128 degrees Fahrenheit.
Report Facts
Resident census: 16 Residents potentially affected: 10 Hot water temperature readings: 128

Employees mentioned
NameTitleContext
Staff AMaintenance staffReported on water temperature checks and hot water heater settings
Administrative staff BAdministrative staffReported no policy regarding checking water temperatures on assisted living

Inspection Report

Deficiencies: 1 Date: Sep 15, 2016

Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

Findings
The survey found the most serious deficiencies to be an 'E' level deficiency, pattern, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective September 26, 2016.

Deficiencies (1)
The facility had an 'E' level deficiency pattern that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Employees mentioned
NameTitleContext
Irina StrakhovaLicensure Certification & Enforcement ManagerSigned the report and communicated findings.

Inspection Report

Re-Inspection
Census: 49 Deficiencies: 1 Date: Sep 7, 2016

Visit Reason
The inspection was a health resurvey to assess compliance with food procurement, storage, preparation, and serving sanitary requirements.

Findings
The facility failed to ensure foods served from the steam table remained at or above 135 degrees Fahrenheit and failed to ensure staff washed their hands between resident contact and plating of food, risking cross contamination and foodborne illness.

Deficiencies (1)
483.35(i) The facility failed to maintain foods on the steam table at or above 135 degrees Fahrenheit during service. Staff also failed to wash their hands after resident contact and before plating food, risking cross contamination.
Report Facts
Facility census: 49 Residents on memory unit: 14 Food temperatures measured below 135 F: 6

Inspection Report

Follow-Up
Deficiencies: 0 Date: Apr 28, 2016

Visit Reason
This visit was conducted as a post-certification revisit to verify correction of previously cited deficiencies.

Findings
The report confirms that all previously reported deficiencies have been corrected as of the revisit date.

Inspection Report

Complaint Investigation
Census: 48 Deficiencies: 1 Date: Apr 15, 2016

Visit Reason
The inspection was conducted as a complaint investigation related to the facility's failure to notify the physician of changes in a resident's condition as requested.

Complaint Details
The investigation was triggered by a complaint (DNRX11) regarding failure to notify the physician of changes in a resident's condition, specifically low oxygen saturations. The complaint was substantiated based on findings.
Findings
The facility failed to assess and notify the physician as requested regarding decreases in oxygen saturations for one resident. Documentation showed multiple instances where low oxygen levels were noted but the physician was not promptly informed as required.

Deficiencies (1)
483.10(b)(11) The facility failed to assess and notify the physician as requested of decreases in a resident's oxygen saturations. Documentation showed multiple low oxygen saturation events without physician notification or lung sound assessments.
Report Facts
Resident census: 48 Residents in sample: 3 Oxygen saturation readings: 53 Oxygen saturation readings: 55 Oxygen saturation readings: 65 Oxygen saturation readings: 73 Oxygen saturation readings: 90 Oxygen saturation readings: 91 Oxygen saturation readings: 92 Oxygen saturation readings: 94 Oxygen saturation readings: 95 Blood pressure: 86 Blood pressure: 51 Pulse: 166 Fluid restriction: 2000 Medication dosage: 1 Medication dosage: 2.5

Inspection Report

Abbreviated Survey
Deficiencies: 1 Date: Apr 13, 2016

Visit Reason
An Abbreviated Survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

Findings
The survey found the most serious deficiency to be a 'D' level deficiency that constitutes no actual harm but has potential for more than minimal harm and is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

Deficiencies (1)
The facility had a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm and is not immediate jeopardy.

Employees mentioned
NameTitleContext
Caryl GillComplaint CoordinatorNamed as contact person and signatory related to the survey findings.

Inspection Report

Life Safety
Deficiencies: 1 Date: Mar 22, 2016

Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

Findings
The survey found the most serious deficiencies to be at 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

Deficiencies (1)
The facility was cited with 'F' level deficiencies indicating no harm but potential for more than minimal harm that is not immediate jeopardy.

Inspection Report

Plan of Correction
Deficiencies: 0 Date: Mar 30, 2015

Visit Reason
The plan of correction addresses the health survey and investigation of complaints #75574 and #78056 at The Wheatlands Health Center.

Findings
The investigation resulted in a finding of no deficiency citations related to applicable regulations under 42 CFR Part 483, Subpart F, for long-term care facilities.

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Mar 30, 2015

Visit Reason
The inspection was conducted as a health survey and investigation of complaints #75574 and #78056 at The Wheatlands Health Care Center.

Complaint Details
Investigation of complaints #75574 and #78056 found no deficiencies.
Findings
The investigation resulted in a finding of no deficiency citations related to applicable regulations under 42 CFR Part 483, Subpart F for long-term care facilities.

Inspection Report

Life Safety
Deficiencies: 1 Date: Aug 12, 2014

Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required and enforcement remedies were recommended if substantial compliance was not achieved.

Deficiencies (1)
The facility was cited for 'F' level deficiencies that were widespread with no harm but potential for more than minimal harm, not immediate jeopardy.
Report Facts
Enforcement effective date: Nov 12, 2014 Provider agreement termination date: Feb 12, 2015 IDR request deadline: 10

Employees mentioned
NameTitleContext
Irina StrakhovaEnforcement CoordinatorSigned the enforcement letter
Brenda McNortonDirector of Fire Prevention DivisionContact for Informal Dispute Resolution process

Inspection Report

Follow-Up
Deficiencies: 0 Date: Jan 9, 2014

Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.

Findings
The report confirms that all previously cited deficiencies identified by regulation numbers have been corrected as of January 9, 2014.

Inspection Report

Follow-Up
Deficiencies: 1 Date: Jan 9, 2014

Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at The Wheatlands Health Care Center.

Findings
The report confirms that the previously identified deficiency under regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) was corrected as of the revisit date.

Deficiencies (1)
Regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c) deficiency was corrected by the revisit date of 2014-01-09.

Inspection Report

Re-Inspection
Deficiencies: 0 Date: Jan 3, 2014

Visit Reason
This visit was a follow-up to verify correction of previously cited deficiencies at The Wheatlands Health Care Center.

Findings
The report documents that all previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.

Inspection Report

Plan of Correction
Deficiencies: 4 Date: Dec 10, 2013

Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection.

Findings
The facility had deficiencies related to posting policies and procedures, posting survey reports, completing Functional Capacity Screenings, and completing Negotiated Service Agreements. Corrective actions and responsible parties are outlined with target completion dates.

Deficiencies (4)
The location and availability of facility policies and procedures were not properly posted. The facility will post them in a locked bulletin board in the assisted living dining room and maintain them.
The location and availability of the facility's survey report were not properly posted. The facility will post the survey report in a locked bulletin board in the assisted living dining room and maintain it.
Functional Capacity Screenings were not consistently completed upon admission, annually, and after significant changes. An audit showed screenings were current as of 12/10/13. The DON will ensure timely completion.
Negotiated Service Agreements were not consistently completed upon admission, annually, and after significant changes. An audit showed agreements were current as of 12/10/13. The DON will ensure timely completion.

Inspection Report

Re-Inspection
Census: 47 Deficiencies: 1 Date: Dec 10, 2013

Visit Reason
This visit was a health resurvey to assess compliance with previously identified deficiencies related to the nursing facility support system.

Findings
The facility failed to ensure an emergency call light was within reach in a common bathing area, specifically in the TLC Angels unit shower area. The call light pull cord was mounted away from the shower and not easily accessible, and the facility lacked a call light policy.

Deficiencies (1)
KAR 26-40-303(h)(1)(B)(i)(ii)(iii)(iv) Nursing facility failed to ensure an emergency call light was within reach in the common bathing area of the TLC Angels unit. The call light pull cord was placed away from the shower and not easily accessible to residents or staff.
Report Facts
Facility census: 47 Residents affected: 13

Employees mentioned
NameTitleContext
Maintenance staff K and administrative nursing staff B and administrative staff A were interviewed regarding the emergency call system and its accessibility.

Inspection Report

Plan of Correction
Deficiencies: 10 Date: Dec 9, 2013

Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified during a prior inspection.

Findings
The plan outlines corrective actions for multiple deficiencies related to resident care plans, fall risk assessments, wound care, and incident reporting. The facility commits to staff training, audits, and monitoring to ensure compliance and improvement.

Deficiencies (10)
F0000 The statement of deficiencies will be taken to the facility's QAPI committee on 01/02/2014.
F252-E Towel bars were labeled to identify resident use, and an audit found no cross contamination issues. Housekeeping and administration will monitor compliance.
F274-D The Interdisciplinary Team will meet weekly to assess significant changes in residents' ADLs and update care plans accordingly.
F279-E A checklist was added to admission packets and wound assessments to ensure skin issues and interventions are updated and monitored.
F280-D A checklist was added to admission packets to update fall risks and interventions, with audits to identify at-risk residents and monitor effectiveness.
F281-D A temporary care plan will be developed upon admission and updated weekly by the interdisciplinary team until a comprehensive plan is completed.
F309-D The facility's Fall Policy and Procedure will be reviewed and updated, including incident reporting and care plan updates, with mandatory staff training.
F323-D The QAPI committee will review and update the Fall Policy with mandatory training on incident reporting and fall risk assessments.
F329-D Resident #55's care plan was updated to monitor behaviors, with mandatory staff training on documentation and interventions before medication use.
S1166-E The call light was moved during the survey to be within residents' reach; maintenance and administration will ensure future compliance.
Report Facts
Date of audit: Dec 17, 2013 Date of training: Oct 9, 2013 Date of inservice: Dec 20, 2013 Date of call light move: Dec 9, 2013

Employees mentioned
NameTitleContext
Sharon RinkeAdministratorAdministrator responsible for monitoring and ensuring future compliance
Irina StrakhovaSubmitted and modified the Plan of Correction

Inspection Report

Renewal
Census: 16 Deficiencies: 4 Date: Dec 5, 2013

Visit Reason
The inspection was a Licensure Resurvey to assess compliance with state regulations for The Wheatlands Health Care Center.

Findings
The facility failed to post notices regarding the availability of policies and procedures and the most recent survey report in places accessible to residents. Additionally, the facility did not complete required annual Functional Capacity Screens and Negotiated Service Agreements for one sampled resident.

Deficiencies (4)
KAR 26-41-101 (g) The facility failed to post a notice of availability of policies and procedures related to resident services in a place readily accessible to residents.
KAR 26-41-101 (l) The facility failed to have the most recent survey report and plan of correction available for examination in a public area accessible to residents.
KAR 26-41-201 (c) The facility failed to complete a Functional Capacity Screen at least once every 365 days for one of three sampled residents.
KAR 26-41-202 (d) The facility failed to complete a Negotiated Service Agreement at least once every 365 days for one of three sampled residents.
Report Facts
Facility census: 16 Days between Functional Capacity Screens: 410 Days between Negotiated Service Agreements: 386

Inspection Report

Follow-Up
Deficiencies: 7 Date: Aug 31, 2012

Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.

Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.

Deficiencies (7)
Regulation 483.20(g)-(j) deficiency was corrected by the revisit date.
Regulations 483.20(d)(3) and 483.10(k)(2) deficiencies were corrected by the revisit date.
Regulation 483.25(d) deficiency was corrected by the revisit date.
Regulation 483.25(h) deficiency was corrected by the revisit date.
Regulations 483.35(d)(1)-(2) deficiencies were corrected by the revisit date.
Regulation 483.35(i) deficiency was corrected by the revisit date.
Regulations 483.60(b), (d), and (e) deficiencies were corrected by the revisit date.

Inspection Report

Plan of Correction
Deficiencies: 8 Date: Aug 31, 2012

Visit Reason
This document is a Plan of Correction submitted by The Wheatlands ALF to address deficiencies identified in a prior inspection.

Findings
The plan outlines corrective actions including dental assessments, care plan reviews after falls, voiding diaries, dietary staff retraining, and insulin storage protocols to ensure compliance with regulatory requirements.

Deficiencies (8)
F278: A dental assessment was completed on residents #24 and #27. Future dental assessments will be completed upon admission and quarterly.
F280: Nurses were re-educated to review care plans after resident falls. Incident forms were modified to include new interventions.
F315: A three-day voiding diary was completed on resident #33 and will be used for new admissions and when incontinence increases.
F323: Nurses were re-educated on reviewing care plans after falls and monitoring interventions weekly at resident care meetings.
F364: Dietary staff received retraining on food preparation, including refrigerating canned fruits and puddings for 24 hours before serving.
F371: Dietary staff were retrained on sanitizer use per manufacturer directions and proper food holding temperatures.
F491: Nurses were re-educated on state and federal laws regarding insulin storage and use. The DON will monitor compliance.
S615: Dietary staff were retrained on sanitizer protocols and the Certified Dietary Manager will monitor compliance and train new employees.

Inspection Report

Re-Inspection
Census: 21 Deficiencies: 1 Date: Aug 20, 2012

Visit Reason
The inspection was a licensure re-survey to assess compliance with dietary service regulations.

Findings
The facility failed to maintain proper chemical sanitizer levels in the three compartment sink, risking unsanitary food storage and distribution that could affect all 21 residents.

Deficiencies (1)
28-39-158(c) Dietary Services: The facility failed to ensure the three compartment sink maintained the manufacturer's recommended chemical sanitizer level of 200 PPM, with observed levels between 0-50 PPM during inspection.
Report Facts
Chemical sanitizer level: 0 Chemical sanitizer level: 200

Employees mentioned
NameTitleContext
Dietary Staff GInterviewed regarding chemical sanitizer levels and sink sanitation.

Inspection Report

Plan of Correction
Deficiencies: 1 Date: N048003 POC DNRX11

Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at the Wheatlands Health Care Center.

Findings
The plan addresses a deficiency related to licensed nurses failing to notify physicians when a change of condition occurs for any resident. Corrective actions include mandatory nurse training and monitoring by the Medicare Nurse and Director of Nursing.

Deficiencies (1)
F157-D: Licensed nurses failed to notify the physician when a change of condition occurred for residents. A mandatory nurses meeting and monitoring process will ensure compliance.

Inspection Report

Plan of Correction
Deficiencies: 0 Date: N048003 POC PR1C11

Visit Reason
This document is a Plan of Correction related to a previous inspection event for the facility identified by State ID N048003 and Event ID PR1C11.

Findings
No deficiency details or findings are included in this Plan of Correction document. It only references the related deficiency report with no records found.

Inspection Report

Plan of Correction
Deficiencies: 1 Date: N048003 POC XO1311

Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.

Findings
The plan addresses infection control deficiencies related to food serving procedures in the dementia wing, including staff education and monitoring to ensure compliance.

Deficiencies (1)
F371-E: Infection control procedures during food serving in the dementia wing were deficient. Staff education and retraining on these procedures were planned, with dietary staff assigned to serve food and monitor temperatures.

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