Warm Springs Medical Center Nursing Home

In the surveyor’s words

From the most serious findings on record at Warm Springs Medical Center Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 17, 2026

  Based on observations, staff interviews, and review of the facility's policies titled, Warewashing and Manual Warewashing (3-Compartment Sink), dietary staff failed to prevent wet-nesting in stored steam table pans to avoid the potential for bacterial growth. The facility census was 76 and all residents were receiving an oral diet.Findings include:Review of the facility's policy titled Warewashing revealed at bullet point number 4, all dishware will be air dried and properly stored.Review of the facility's policy titled Manual Warewashing (3-Compartment Sink) revealed at bullet point number 2, all serviceware and cookware will be air dried prior to storage.Observation on 05/15/2026 at 9:15 AM of the pot and pan rack revealed several stacks of steam table pans. […]

• No harm, potential for more than minimal, widespreadF812Nov 5, 2023

  Based on observations, staff interviews, and a review of the facility policy titled, Safe Food Handling, the facility failed to ensure one of three reach-in freezers were clean and free from debris; failed to ensure inside the ice machine was clean and free from residue. The facility failed to ensure dietary staff washed hands and changed gloves in the dish room to prevent cross contamination. The facility census was 76 with 74 residents receiving an oral diet. Findings include: 1. […]

• No harm, potential for more than minimal, patternF607Nov 5, 2023

  Based on record review, staff interviews, and review of the policy titled Abuse Program Policy and Procedures, the facility failed to ensure pre-employment screening, specifically reference checks, were conducted prior to employment for 10 of 33 employees. The census was 76 residents. Findings include: Review of the undated policy titled Abuse Program Policy and Procedures, the policy included to maintain an environment free of abuse and neglect. The Procedure section stated: Line numbered 1. All potential new employees and volunteers will be screened for a history of abuse, neglect, or mistreatment of residents. Line numbered 2. Screening of potential employees will include requesting information from previous and/or current employers. […]

• No harm, potential for more than minimal, patternF727Nov 5, 2023

  Based on record review and staff interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, for seven days a week for 13 days (6/1/2023, 6/5/2023, 6/7/2023, 6/9/2023, 6/15/2023, 6/19/2023, 6/21/2023, 6/25/2023, 6/26/2023, 6/27/2023, 10/3/2023, 10/17/2023, and 10/27/2023). The census was 76. Findings include: Review of the PBJ Staffing Data Report for FY Quarter 3 2023 revealed no RN hours for 6/7/2023, 6/9/2023, 6/13/2023, 6/19/2023, 6/23/2023, 6/26/2023, 6/27/2023, 6/28/2023, and 6/30/2023. Review of the Facility Two-Week Staffing Grid for 10/17/2023 through 10/30/2023 revealed no RN hours on 10/17/2023 and 10/27/2023. […]

• No harm, potential for more than minimal, patternF804Apr 21, 2022

  Based on observation, interview, and review of facility policy, the facility failed to ensure that a lunch meal remained hot upon delivery to residents. This had the potential to affect 18 residents on the hall. Findings include: Interviews with residents, including R A on 4/19/22 at 9:30 a.m., revealed that the food is always cold. Sometimes, the food is served in a Styrofoam box which makes it even colder. Observation on 4/20/22 at 12:30 p.m. revealed the Dietary Manager and Dietary Aide brought a closed meal cart to the floor. The cart remained on the floor for six minutes before a staff member began to pass trays to the residents. The last tray was distributed 28 minutes from the start time. […]