Meadow Green Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure one Resident (#72) with a history of pressure ulcers, and assessed as being at high-risk for the development of pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, out of a total sample of 30 Residents. Specifically, the facility failed ensure the air mattress turned on while the Resident was in bed.Findings include: Review of the facility policy titled 'Support Surface Guidelines', updated 8/1/23, indicated the following:-The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown.-Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air loss or gel while lying in bed.-Use a pressure…

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

Based on record review and interview, the facility failed to ensure that recommendations made by the Consultant Pharmacist during the Monthly Medication Review (MMR) were addressed for two Residents (#2 and #65) out of a total sample of 30 residents. Specifically, the facility failed to review and implement recommendations from the Consultant Pharmacist in regard to a stop date for as needed (PRN) psychotropic medications. Findings include:Review of facility policy titled Consults: Pharmacy, [named facilities consulting provider], wound MD and other outside consultants, dated as updated 8/1/23, indicated the following: -Residents who have consultants will have recommendations reviewed by attending MD/NP/PA/LIP (physician/ nurse practitioner, physician's assistant, licensed independent practitioner).-Staff will review consultation report and or recommendations with prescriber.-Prescriber will make decision on if recommendations are followed and orders obtained.-Nursing will document new orders and. will order supplies if necessary.-Nursing will document per house protocol. 1a.…

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

Based on record review and interviews, the facility failed to ensure that medications were accurately reconciled by nursing for one Resident (#104), out of a total sample of 30 residents, to ensure he/she was free from a significant medication error. Specifically, the facility failed to ensure Cefadroxil (an antibiotic medication) was accurately transcribed in the medical record upon admission to the facility, resulting in the Resident not receiving the complete course of antibiotics. Findings include: Review of facility policy titled Administering Medications dated as updated 8/1/23, indicated the following:-Medications are administered in accordance with prescriber orders, including any required time frame. Resident #104 was admitted to the facility in January 2026 with diagnoses that included fracture of the shaft of the left tibia and encounter for orthopedic aftercare. There is no MDS information available for Resident #104. Review of admission paperwork from the referring acute care hospital indicated the following:-Start cefadroxil 500 mg (milligrams) capsule, 1 capsule by…

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

Based on record review and interview the facility failed to maintain accurate medical records for two Residents (#15 and #61) out of a total sample of 30 residents. Specifically:For Resident #15 the facility documented that weights were obtained when they were not.For Resident #61 the facility documented that weights were obtained when they were not.Findings include: Review of the facility policy titled Charting and Documentation, dated revised 8/1/23, indicated that documentation in the medical record will be objective, complete and accurate. 1. Resident #15 was admitted to the facility in July 2025 with diagnoses including dementia, bipolar disorder and kidney disease. Review of the Minimum Data Set assessment, dated 10/31/25, indicated Resident #15 was severely cognitively impaired, scoring a 6 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #15 requires assistance with all activities of daily living. Review of the weight record for Resident #15 indicated that the last weight was obtained on 10/31/25. Review of the physician's…

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

Based on record review and interview the facility failed to inform each resident of services available in the facility and the charges for those services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices (SNF/ABNs) to two out of two applicable records reviewed. During an interview on 2/26/25 at 2:00 P.M., Social Worker #2 said she had never issued an ABN before. She said that it was the business office that issued the ABNs. During an interview on 2/27/25 at 10:54 A.M., the Administrator said the facility is not issuing the ABNs, but they should be.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice were provided for four Residents (#27, #21, #13 and #93) out of sample of 25 residents. Specifically, 1. For Resident # 27, the facility failed to include an oxygen physician's order in the medical record and have oxygen set at the right flow rate. 2. For Resident #21, the facility failed to routinely change and date oxygen tubing for one Residents. 3. For Resident #13, the facility failed to properly store the nebulizer tubing and mask. 4. For Resident #94, the facility failed to properly store and label the nebulizer tubing and mask. Findings include: A review of the policy titled 'Oxygen Administration' with a revision date of 8/1/23 indicated the following: -The purpose of this procedure is to provide guidelines for safe oxygen administration. -Verify that there is a physician's order for this procedure. Review the physician's orders or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment that prevents the development and transmission of communicable diseases and infections when the facility failed to implement Enhanced Barrier Precautions for three Residents (#306, #95, and #40) out of a total sample of 25 residents and staff wore gloves in the hallways and failed to perform hand hygiene following glove removal. Findings include: 1. Review of facility policy titled Enhanced Barrier Precautions, dated as updated 8/1/23, indicated the following: -Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. -EBPs are targeted gown and glove use during high contact resident care activities when contract precautions do not otherwise apply. -Gloves and gown are applied prior to performing the high contact resident care activity.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide a dignified environment for two Residents (#33 and #27) out of a sample of 25 residents. Specifically, 1. For Resident #33, the facility staff referred to the Resident by their level of assistance. 2. For Resident #27, the facility staff assisted the Resident with a meal while standing and referred to the Resident by their level of assistance. Findings include: A review of the facility policy titled 'Dignity' with a revision date of 8/1/23 indicated the following: -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. -Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not 'labeling' or referring to the resident by his or her room number, diagnosis, or care needs. 1. Resident # 33…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) for two Residents (#11 and #95), out of a total sample of 25 residents were consistently documented in the medical record. Findings include: Review of facility policy titled Advance Directives, dated as updated [DATE], indicated the following: -The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. -Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advanced directives. -If the resident does not have an advance directive: -1. If…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to implement care plans for three Residents (#56, #46 and #32), out of a total of 25 sampled residents. Specifically: 1. For Resident #56, who has a history of putting non-food items into his/her mouth, the facility failed to implement the Resident's care plan of removing potentially hazardous items from the Resident's tray. 2 a. For Resident #46, the facility failed to implement supervision during meals as part of his/her Activities of Daily Living care plan. 2 b. For Resident #32, the facility failed to implement supervision during meals as part of his/her nutritional and Activities of Daily Living care plan. Findings Include: Review of the facility policy titled Activities of Daily Living (ADL), last revised 8/23, indicated the following: Policy Statement -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Policy Interpretation…

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

Based on record review and interview, the facility failed to ensure care and services are provided according to accepted standards of clinical practice for one Resident (#306) out of a total sample of 25 residents. Specifically, for Resident #306, the facility failed to obtain daily weights as indicated in physician's orders. Findings include: Review of the facility policy titled Weight Assessment and Intervention, dated as updated 8/1/23, indicated Residents are weighed upon admission and at intervals established by the interdisciplinary team. Resident #306 was admitted to the facility in February 2025 with diagnoses that include acute respiratory failure with hypoxia and retention of urine Review of Resident #306's physician's orders, dated 2/15/25, indicated daily wts (weights) if >3lbs. (pounds) in one day or >5 lbs. in one week call MD/NP (Medical Doctor/ Nurse Practitioner). Review of the weights portal in the electronic medical record (EMR) indicated the following weights: 2/14/25 192.0 Lbs. 2/16/25 192.9 Lbs. 2/21/25 192.0 Lbs. 2/22/25 191.9 Lbs. Review of the February 2025…

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

Based on interview and record review the facility failed to ensure that one Resident (#65), out of a total sample of 25 residents, received proper treatment to maintain vision ability. Specifically, the facility failed to refer Resident #65 to a retina specialist for further evaluation as recommended by the optometrist. Findings Include: Review of the facility policy, titled Ancillary Services, updated 8/1/23, indicated, but was not limited to, the following: - Residents will be offered ancillary services including, but not limited to, ophthalmology, audiology, podiatry and psych services. If resident chooses services outside of ancillary services provided at the facility all efforts will be made to ensure they are seen. (sic.) - Schedule of services will be provided with as much information as possible, in a timely fashion as possible. - Nursing staff will be responsible for reviewing any and all recommendations from the ancillary services and communicate that to the attention of the attending MD (medical doctor)/NP (nurse practitioner)/PA (physician assistant) for approval or…

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

Based on observation, record review and interview the facility failed to ensure one Resident (#95) with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing out of a total sample of 25 residents. Specifically, the facility failed to ensure recommendations from the consulting wound physician were implemented and that physician's order were in place for an air mattress. Findings include: Review of facility policy titled Ancillary Services, dated as updated 8/1/23, indicated that nursing staff will be responsible for reviewing any and all recommendations from the ancillary services and communicate that to the attention of the attending MD/NP/PA (Medical Doctor/ Nurse Practitioner/ Physician Assistant) for approval or refusal of recommendations. Review of facility policy titled Support Surface Guidelines, dated as updated 8/1/23, indicated support services alone are not effective in preventing pressure ulcers, but studies indicate that the use of…

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

Based on observations, interviews and record review, the facility failed to maintain professional standards in the management and care for urinary catheter devices for one Resident (#306) out of a total sample of 25 residents. Specifically, the facility failed to ensure the urinary catheter drainage bag was not placed directly on the floor. Findings include: Resident #306 was admitted to the facility in February 2025 with diagnoses that include acute respiratory failure with hypoxia and retention of urine Review of Resident #306's physician's orders indicated the following: -Secure to thigh, keep foley (urinary catheter) bag below bladder and provide privacy bag every shift, dated 2/14/2025. -Record foley catheter output every shift, dated 2/14/25. -Irrigate foley with 60ml normal saline as needed for blockage daily, dated 2/14/2025. -On 2/26/25 at 6:57 A.M., the surveyor observed the resident lying in bed. His/her urinary catheter drainage bag was resting on the floor. -On 2/26/25 at 7:17 A.M., Resident #306 was heard yelling for help from his/her room. Three nurses entered the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain an accurate medical record for one Resident (#21) out of a total sample of 25 residents. Specifically, the nurses documented in the Treatment Administration Record (TAR) that oxygen tubing was replaced when it was not. Findings Include: Review of the facility policy titled charting and Documentation, dated 8/23, indicated the following: Policy Statement -All services provided to the residents, progress toward the care plan goals, and any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care Policy Interpretation and Implementation -Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Resident #21 was admitted to the facility in October 2023 with…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required assistance from two staff members for transfers, the Facility failed to ensure they developed and implemented a comprehensive care plan that included interventions, goals, and outcomes related to his/her transfer status. Findings include: The Facility's Policy, titled Comprehensive, Person-Centered Care Plans, dated 08/01/23, indicated the interdisciplinary team, in conjunction with the resident and his/her family or legal representative, would develop and implement a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs for each resident. The Facility's Policy, titled Safe Lifting and Movement of Residents, dated 08/01/23, indicated resident safety, dignity, comfort, and medical conditions would be incorporated into goals and decisions regarding safe lifting and moving of residents, and nursing staff, in conjunction with rehabilitation staff, would assess the resident's…

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

Based on record review and interview, the facility failed to file and resolve grievances brought to the Resident Council group for four months. Findings include: Review of the policy titled, Grievances, dated 8/1/23, indicated the following: -Our facility will assist residents, their representatives, family members or resident advocates in filing a grievance/concern form when concerns are expressed, which may not be able to be handled immediately by the facility staff, requires further investigation or requires consultation with other facility staff, the attending physicians or outside service providers. -Any resident, his/her representative, family member or advocate may file a grievance/concern form regarding treatment, facility services, medical care, behavior or other residents or staff members, theft of property, missing items, discrimination, etc. without fear of threat or reprisal in any form. -The facility will post information on how to file a grievance and information on the name, phone number and contact information (including mail and email) for the facility grievance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, policy review, and interviews the facility failed to 1.) ensure that medications were properly labeled after opening in three of three medication carts observed on three of three nursing units. 2.) ensure medication carts were locked when unattended on one of three nursing units. Findings include: Review of the facility policy titled Medication Labeling and Storage. dated [DATE], indicated the following: -The facility stores medications and biologicals in locked compartments. -Compartments containing medications, including carts, are locked when not in use. -The medication label includes, at a minimum: expiration date, when applicable. -Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date or the open vial. 1. The following was observed in the medication carts: On [DATE] at 7:21 A.M., the surveyor observed the following In the Glenside medication cart: -1 bottle of Liquacel protein supplement,…

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

Based on observations and interviews the facility failed to ensure it was administered in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility administration failed to 1) ensure education and training was provided to all staff to provide competent, safe, and effective resident care, 2) ensure the grievance procedure was being completed in the facility and 3) ensuring the governance and leadership members sustain a sufficient Quality Assurance Performance Improvement (QAPI) program. 1. During the survey process, the following was identified: Review of the facility assessment indicated the following competencies need to be completed by staff: -Self-testing competency for staff to perform COVID-19 binax testing weekly and according to DPH guidelines. -Person centered care - this should include but not be limited to person centered care planning, education or resident and family resident/representative about treatments and medications, documentation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review including the Facility Assessment and facility policies, the facility failed to ensure that the governing body provided oversight and accountability for: 1. ensuring the facility was following the grievance process and completing grievances; 2. ensuring education and competencies were completed per Facility Assessment process/program; 3. ensuring quality of care related to abuse was maintained for two Residents (#5 and #47); 4. ensuring the governance and leadership members sustain a sufficient QAPI program during transitions in leadership and staffing. As a result of the governing body's failure, the facility failed to develop a plan to ensure the facility could safely provide the services to meet the needs of the residents as well as implement an effective QAPI program. Findings include: Review of the Facility Assessment, dated as reviewed on 1/4/24, failed to list who was a member of the Governing Body for the facility. During an interview on 3/12/24 at 12:10 P.M., the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program which addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to: 1) ensure an ongoing, effective QAPI program is implemented and maintained, 2) identify and prioritize problems and opportunities that reflect organizational process, functions, and services provided to residents based on resident and staff input, and other information and 3) ensure the governance and leadership members sustain a QAPI program during transitions in leadership and staffing. Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership, updated 8/1/23, indicated that the responsibilities of the QAPI committee…

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

Based on record review and interview the facility failed to develop and implement policies addressing: (a) How they will use a systematic approach to determine underlying causes of problems impacting larger systems; (b) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems. (c) how the facility will develop acceptable performance benchmarks and; (d) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. Findings include: Review of the facility policy titled Quality Assurance Performance Improvement Plan (QAPI) Governance and Leadership, and updated 8/1/2023, failed to indicate the following: (a) How they will use a systematic approach to determine underlying causes of problems impacting larger systems; (b) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems. (c) how the facility will…

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

Based on observation and policy review, the facility failed to ensure staff followed infection control standards. Specifically,: 1. the facility failed to ensure staff followed droplet precautions while providing care and housekeeping services in rooms with droplet precautions in place on two of three nursing units; and 2. failed to have measures in place to prevent the spread of water borne infections. Findings include: 1. Review of the facility policy titled Isolation-Categories of Transmission-Based Precautions, dated 8/1/23, indicated the following: -For a resident on droplet precautions masks are worn prior to entering thee room. -If there is a risk of spraying respiratory secretions, a gown, gloves and goggles are worn. -Contact Precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. Contact Precautions include the wearing of a disposable gown upon entering the room and remove…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and policy review the facility 1) failed to provide a dignified existence for three Residents (#26, #7, #39) while dining, 2) failed to provide dignity during care for two Residents (#62 and #45 ) and 3) failed to provide a dignified dining experience in 2 of 3 unit dining rooms. Specifically: 1. For Residents #26, #7 and #39, the residents did not receive the needed assistance at meals and resorted to eating non-finger food items with their hands at meals. 2. For Residents #62 and #45 staff failed to provide privacy during Activity of Daily Living Care. 3. For residents on the [NAME] and Pondview Units the staff failed to ensure dignity while dining. Findings include: Review of the facility policy titled, Dignity, dated 8/1/23, indicated the following: -Each residents shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self- esteem. -Residents are treated with dignity and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and interview, the facility failed to report allegations of abuse for seven Residents (#5,#26, #62, #90, #100, #19 and #108) within the required two hour time frame out of a total sample of 41 residents. Findings include: Review of the Facility policy titled, Resident Rights/Abuse, undated, indicated the following: -Federal requirements state that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion; And that we may not mistreat, neglect, abuse, or misappropriate the resident's property. -Emotional abuse happens when a resident is humiliated, harassed or feels threatened. -Psychological abuse - causing emotional pain or distress to a resident. Cytological abuse includes but is not limited to: humiliation. -Signs of psychological abuse may include the resident suddenly becoming fearful, withdrawn, refuses to eat, sleeps poorly at night, ringing the bell more frequently because the resident is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to complete a significant change Minimum Data Set (MDS) assessment within the required time frame for two Residents (#22 and #51) out of a total sample of 41 residents. Findings include: 1. Resident #22 was admitted to the facility in July 2021 with diagnoses including depression and malnutrition. Review of Resident #22's current physician's orders, dated 1/04/24, indicated an order for a hospice evaluation and admit if appropriate. Review of the clinical progress notes indicated a note, dated 1/12/2024, that Resident #22 was admitted to hospice on 1/12/24. Review of the medical record failed to indicate that a significant change MDS was completed within the required time frame following an admission to hospice services. During an interview on 3/07/24 at 11:00 A.M., the Assistant Director of Nursing (ADON) said that when a resident is admitted to hospice services a significant change MDS must be completed. During an interview on 3/11/24, at 12:41 P.M., the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, interviews and policy reviews, the facility failed to follow the plan of care and develop personalized care plans for six Residents (#39, #49, #100, #34, #60 and #71). Specifically, 1. for Resident #39, the facility failed to ensure Fall Eaze mats were in place, as ordered by the physician; 2. For Resident #49, the facility failed to develop a cognitive care plan to address dementia; 3. For Resident #100, the facility failed to a) follow the plan of care to off load the Resident's heel and b) develop a care plan for the diagnosis and behaviors of [NAME] (An eating disorder characterized by a tendency to eat substances that provide no nutritive value such as soil, chalk, hair, paper, etc.); 4. For Resident #34, the facility failed to develop a care plan for the Resident's contracture's; 5. For Resident #60, the facility failed to ensure fall mats were in place as ordered; and 6. For Resident #71, the facility failed to develop and subsequently follow a care plan for [NAME]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record the facility failed to ensure assistance with Activities of Daily Living (ADLs) was provided for 16 Residents (#5, #50, #60, #62, #82, #97, #26, #39, #224, #62, #90, #19, #100, #108 #97, #47) out of a total sample of 41 residents. Specifically, 1. for Residents #5, #50, #60, #82, #97, #26, #39 and #224 the facility failed to ensure feeding assistance and supervision with meals was provided. Resident #5's lack of supervision resulted in the Resident having a burn from hot coffee; 2. For Resident #26, #62, #90 #19, #100, #108 #97 and #82, the facility failed to ensure incontinence care was provided as required. 3. For Resident #47, the facility failed to provide assistance with hygiene. Findings include: Review of the facility policy titled, Activities of Daily Living, Supporting, dated 8/1/23, indicated the following: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living…

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

Based on in-service documentation review, employee record review and interview, the facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility failed to ensure annual competencies were completed and documented for four out of four Certified Nursing Assistants (CNAs), and four out of four licensed nurses whose education records were reviewed. Findings include: The facility failed to produce a policy and procedure for ensuring nursing staff competency. Review of four out of four CNA employee records and four out of four licensed nurse's employee records failed to indicate yearly competencies, as determined by the needs of the residents based on the facility assessment, were completed. During an interview on 3/11/24 at 4:30 P.M., the Assistant Director of Nursing (ADON) said that she was not able to locate competencies for 8 out of 8 of the employee records reviewed. The ADON said that she did not know who was responsible for oversight of the completion of staff…

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

Based on employee record review and interview, the facility failed to complete a performance review of Certified Nursing Assistants (CNAs) at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews for 4 out of 4 CNAs employee records reviewed. Findings include: Review of the facility policy titled In-Service Training, Nurse Aide, dated as updated 8/1/23, indicated that annual in-services are to address areas of weakness as determined by nurse aide performance reviews. During an interview on 3/11/24 at 4:30 P.M., the Assistant Director of Nursing (ADON) said that she was not able to locate performance reviews for 4 out of 4 of the CNA records reviewed. The ADON said that she did not know who was responsible for oversight of CNA performance reviews.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to maintain accurate medical records for five Residents (#122 #26, #39, #48, #84) out of a total sample of 41 residents. Findings include: 1. Resident #122 was admitted to the facility in January 2024 with diagnoses including cancer, malnutrition and depression. Review of a nurse's note dated 1/12/24 at 2:59 P.M., indicated Resident #122 was scheduled for an appointment with a pick up time of 8:00 A.M Review of a nurse's note dated 1/12/24 at 4:33 P.M., indicated Resident #122 refused a skin check. Review of the Medication Administration Record dated 1/12/24, indicated that Resident #122 was not in the facility after 8:00 A.M., and was not in the facility to refuse the skin check at 4:33 P.M Review of a nurse's note dated 1/13/24 at 4:44 P.M., indicated Resident #122 was discharged against medical advice. Further review failed to indicate when the Resident was discharged , where the Resident was discharged to, with whom the Resident was discharged or that…

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

Based on record review and interview the facility failed to ensure Certified Nurse's Assistants (CNAs) received the required in-service training. Specifically, the facility: 1.) failed to provide no less than 12 hours of training per year; 2.) failed to include dementia management training as required; and 3.) failed to address areas of weakness as determined in CNA's performance reviews, for four out of four CNA employee records reviewed. Findings include: Review of the facility policy titled In-Service Training, Nurse Aide. dated 8/1/23, indicated that Annual in-services are no less than 12 hours per employment year; include training in dementia. 1. Review of CNA #6's employee records failed to indicate any education/orientation trainings since the date of hire. Further review indicated that the 8 hour initial dementia training did not occur until 1/26/24, 3 months after hire. 2. Review of CNA #5's employee records failed to indicate the 8 hour initial dementia education training was provided until 1/26/24, 6 months after date of hire. Further review failed to indicate the number…

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

Based on record review and interviews, the facility failed to obtain consents for psychotropic medication, outlining the risks and benefits of treatment, prior to administering psychotropic medication for two Residents (#97, and #82) out of a sample of 41 residents. Findings include: A review of the facility's policy titled Psychotropic Medication Use, dated August of 2023, indicated the following: -Residents, families, and/or representative are involved in the medication management process. Psychotropic medication management includes: a. indications for use; b. dose (including duplicate therapy); c. duration; d. adequate monitoring for efficacy and adverse consequences; and e. preventing, identifying, and responding to adverse consequences. 1. Resident #97 was admitted to the facility in October 2023 with diagnoses including: Alzheimer's, major depressive disorder, anxiety, dementia, adult failure to thrive, aphasia, and dysphagia. Review of the Minimum Data Set (MDS) assessment, dated 12/2/23, indicated Resident #97 had a Brief Interview for Mental Status (BIMS) score of 0 out of…

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

Based on observation, record review and interview, the facility failed to ensure one Resident (#50) was assessed for the ability to self-administer medications out of a total sample of 41 residents. Findings include: Review of the facility policy titled Administering Medications, dated 8/1/23, indicated the following: 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making ability to do so safely. Resident #50 was admitted to the facility in February 2023 with diagnoses including cognitive communication deficit, muscle weakness, and diabetes. Review of Resident #50's most recent Minimum Data Set (MDS) assessment, dated 12/21/23, indicated Resident #50 had a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15 which indicated moderate cognitive impairment. Further review of the MDS indicated that he/she is dependent on staff for functional tasks. During an observation on 3/5/24 at 7:52 A.M., Resident #50 was sitting in…

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

Based on observations, record review and interview, the facility failed to ensure a call light was within reach for one Resident (#7) out of a total sample of 41 residents. Findings include: Review of the policy titled, Call System, Residents, dated 8/1/23, indicated the following: -Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. -Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Resident #7 was admitted to the facility in November 2023 with diagnoses including stroke, heart failure and anxiety. Review of Resident #7's most recent Minimum Data Set (MDS) assessment, dated 1/6/24, indicated Resident #7 had a Brief Interview for Mental Status exam score of 11 out of a possible 15, which indicated the Resident had moderate cognitive impairment. The MDS also indicated Resident #7 required assistance from staff for all functional tasks. On 3/07/24 from 6:20 A.M., to 6:48 A.M.,…

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

Based on observations and interviews, the facility failed to ensure resident's Protected Health Information (PHI) was secure and not visible to others on two of three nursing units. Findings include: Review of the facility policy titled Resident Rights, updated 8/1/23, indicated that residents have the right to privacy and confidentiality. On 4/29/24, at 7:00 A.M., the surveyor observed a medication cart on the Glenside unit to have the computer screen open and exposing a resident's personal medical information. The surveyor also observed 3 nurses at the nurse's station approximately 25 feet away with their backs towards the medication cart. The surveyor also observed several residents in the hallway, passing by the open screen. On 4/29/24, at 7:15 A.M., the surveyor observed a medication cart on the Pond View unit to have the computer screen open and exposing a resident's personal medical information. The surveyor also observed that the nurse was not on the unit and the cart was not in their line of site. The surveyor also observed several residents in the hallway able to visualize…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility 1. failed to make information on how to file a grievance or complaint available to the residents of the facility and 2. failed to file and resolve grievances for three Residents (#47, #100 and #5) out of a total sample of 41 residents. Findings include: Review of the policy titled, Grievances, dated 8/1/23, indicated the following: -Our facility will assist residents, their representatives, family members or resident advocates in filing a grievance/concern form when concerns are expressed, which may not be able to be handled immediately by the facility staff, requires further investigation or requires consultation with other facility staff, the attending physicians or outside service providers. -Any resident, his/her representative, family member or advocate may file a grievance/concern form regarding treatment, facility services, medical care, behavior or other residents or staff members, theft of property, missing items, discrimination, etc. without fear of…

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

Based on observations, interviews and records reviewed for one resident (Resident #101) of 41 sampled residents, the facility failed to prevent the use of restraints without appropriate assessment. Findings include: Review of the facility policy titled, Use of Restraints dated 8/1/23, indicated the following: -Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. -Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience or for the prevention of falls. -Physical restraints are defined as any manual method or physical or medical device, material or equipment attached or adjacent to the resident's body that the individual cannot easily remove, which restricts freedom of movement or restricts normal access to one's body. -Prior to placing a resident in restraints, there shall be a prerestraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interviews, the facility failed to implement their abuse policy for one Resident (#5) out of a total sample of 41 residents. Specifically, the facility failed to implement a timely investigation and report within the required two hour time frame to the Department of Public Health's (DPH's) Health Care Facility Reporting System (HCFRS) when Resident #5 reported that a Certified Nursing Assistant (CNA) forced Resident #5, against his/her will, to take a shower and purposefully sprayed water in his/her face during the process. Review of the Facility policy titled, Resident Rights/Abuse, undated, indicated the following: -Federal requirements state that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion; And that we may not mistreat, neglect, abuse, or misappropriate the resident's property. -Emotional abuse happens when a resident is humiliated, harassed or feels threatened. -Psychological…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review and policy review, the facility failed to investigate allegations of abuse for 2 Residents (#5 and #47) out of a total sample of 41 residents. Findings include: Review of the Facility policy titled, Resident Rights/Abuse, undated, indicated the following: -Federal requirements state that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion; And that we may not mistreat, neglect, abuse, or misappropriate the resident's property. -Emotional abuse happens when a resident is humiliated, harassed or feels threatened. -Psychological abuse - causing emotional pain or distress to a resident. Cytological abuse includes but is not limited to: humiliation. -Signs of psychological abuse may include the resident suddenly becoming fearful, withdrawn, refuses to eat, sleeps poorly at night, ringing the bell more frequently because the resident is afraid. -Neglect - the failure to provide goods and services…

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

Based on record review and interview, the facility failed to provide a copy of the transfer/discharge notice upon transfer to the hospital for one Resident (#121) out of a total sample of 41 residents. Findings include: The facility failed to produce a policy for the transfer/discharge of a resident upon request by the surveyor. Resident #121 was admitted to the facility in January 2024 with diagnoses including Covid-19 and heart failure. Review of the medical record indicated that Resident #121 was discharged to the hospital on 1/10/24. Further review failed to indicate that Resident #121, or his/her representative, was given the required transfer/discharge notice. During an interview on 3/06/24 at 10:03 A.M., the Director of Nursing said that she had not been able to locate the transfer/discharge notice for Resident #121 and this notice should have been provided to the Resident or his/her representative.

Based on interview, record review and policy review, the facility failed to complete quarterly care plan meetings for two Residents (#48 and #51) out of a total sample of 41 residents. Findings include: Review of the facility policy titled, Care Planning - Interdisciplinary Team, indicated the following: -The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. -Care plan meetings are scheduled at the best time of the day for the resident and family when possible. -If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record. 1. Resident #48 was admitted to the facility in March 2015 with diagnoses including arthritis and neuropathy. Review of Resident #48's most recent Minimum Data Set (MDS) assessment, dated 1/06/24, indicated Resident #48 had a Brief Interview for Mental Status exam score of 15 out of a possible 15, which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, observation, and interview, the facility failed to ensure staff administered medication in a manner that met professional standards of care for one Resident (#48) out of a total sample of 10 residents. Specifically, staff failed to administer lidocaine patches per the physician's order. Findings include: Review of the facility policy, titled Administering Medications, updated August 2023, indicated, but was not limited to, the following: -Medications are administered in accordance with prescriber orders, including any required time frame. -Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; and c. honoring resident choices and preferences, consistent with his or her care plan. -Medications are administered within one (1) hour of their prescribed time, unless otherwise…

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

Based on observations, interviews, and policy review the facility failed to provide an activities program that met the interest of, and supported the physical, mental, and psychosocial well-being of one Resident (#54) out of a total sample of 41 residents. Findings include: Review of the facility policy titled Activities, updated August 2023, indicated the following: -Activities department will develop activities suited for our residents in accordance with all state and federal regulations. -Activities will be developed under the direction of the activity coordinator. - The calendar shall reflect planned group activities, be posted, and large enough for the vision impaired. -The activity assistants shall be responsible for distributing the calendars within the nursing home. -An activity program shall be developed for each and every resident, according his/her needs and interest (sic.) -All residents shall be encouraged and assisted to be involved in whatever level is appropriate for the resident. -Individual programming shall include one or more of the following: a. Group activities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a safe environment for two Residents (#71, and #12) out of a total sample of 41 residents to prevent accidents/incidents. Specifically: 1. For Resident #71 the facility failed to provide supervision to prevent the Resident from placing non edible items into his/her mouth creating a choking risk. 2. For Resident #12 the facility failed to provide supervision while consuming hot coffee. Findings include: The facility policy titled Accidents and Incidents-Investigating and Reporting, dated 8/1/23, indicated the following: -All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. 1. The nurse supervisor/charge nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable shall be included on the Report of Incident/Accident…

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

Based on observations, interviews and record reviews, the facility failed to provide dental services for one Resident (#64) out of a total of 41 residents. Findings include: Review of the policy titled, Dental Services, dated 8/1/23, indicated the following: *Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. *Routine and 24-hour emergency dental services are provided to our residents through: a. A contract agreement with a licensed dentist that comes to the facility monthly; b. Referral to the resident's personal dentist. c. Referral to community dentist; d. Referral to other health care organizations that provide dental services. Social Service representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. *Dentures will be protected from loss or damage, to the extent practicable, while being stored. *Lost or damaged dentures will be replaced at the resident's expense unless…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to provide the correct ordered therapeutic diet to ensure safety while eating for three Residents (#19 #5 and #60) out of a total sample of 41 residents. Specifically, 1) Resident #19 was not provided with pureed vegetables as ordered, 2) Resident #5 was not provided with ground diet as ordered, 3) Resident #60 was provided with foods not adhering to his/her ground diet. Findings include: Review of the facility policy titled Therapeutic Diets, dated 8/1/23, indicated the following: -Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. -A therapeutic diet: is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: d. altered consistency diet. -If a mechanically altered…

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

Based on record review, document review and interview the facility failed to ensure that hospice services meet professional standards and principles that apply to individuals providing services in the facility, and have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. Specifically: 1) the facility failed to ensure a coordinated person-centered care plan with individualized interventions were developed for the provision of hospice care services and failed to ensure ongoing documentation of hospice staff visits to ensure prompt and effective communication and continuity of care for for two Residents (#58 and #97) out of a total sample of 41 residents, 2) the facility failed to ensure a physician's order for the provision of Hospice care was obtained for one Resident (#97) and 3) the facility failed to have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized…

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

Based on review of the Facility Assessment, employee education record review, and interview, the facility failed to implement and maintain and effective training program per the facility assessment for all new and existing staff. Specifically, the facility failed to provide the required training necessary to meet the needs of each resident. Findings include: Review of the Facility Assessment, indicated but was not limited to: - Staff training/education and Competencies - Each employee at the facility is given competencies based on their position. Upon hire and annually, staff receive both education and competencies. Competency assessments are based upon the employee's job description/responsibilities and the relevant company policies and procedures that pertain to each particular position. - The facility provides continuous education and training for all our staff. We have a full-time registered nurse as our staff development coordinator (SDC). Our SDC is continually educating staff through presentations, educational fairs, and on the floor in services. - Additionally, the facility…

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