Scotland Manor Health and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews with the resident, staff, and Medical Director, the facility failed to follow up with an audiologist's (a medical professional that specializes in the diagnosis, evaluation and treatment of hearing disorders) recommendation for ear wax removal for 1 of 1 resident reviewed for hearing difficulties (Resident #21).The findings included:Resident #21 was admitted to the facility on [DATE] with diagnoses which included stroke. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #21 had moderate cognitive impairment. Resident #21 was coded for minimal hearing difficulty and no hearing aid.The care plan, last reviewed on 10/30/25, revealed Resident #21 had a communication problem related to hearing deficit with interventions which included repeating as necessary, face the resident while speaking, and speaking clearly and slower than normal. The Audiology (scientific study of hearing and balance) visit summary dated 12/12/24 revealed Resident…

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 staff interviews, the facility failed to follow physician orders to change oxygen supplies, which included the nasal cannula, for 1 of 1 resident reviewed for respiratory care (Resident #21). The findings included:Resident #21 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #21 had moderate cognitive impairment. Resident #21 was coded for supplemental oxygen use. The care plan last reviewed on 10/30/25, revealed Resident #21 was at risk for shortness of breath related to COPD with interventions which included to administer oxygen as ordered.Resident #21 had a physician order dated 10/08/25 to change oxygen supplies (nasal canula tubing, humidifier bottles) every 7 days when oxygen is in use. Every night shift, every Wednesday for oxygen cannula. Review of the Medication Administration Record (MAR) for November 2025 revealed…

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 staff interviews, the facility failed to ensure a medical record was accurate regarding oxygen nasal cannula changes. This was for 1 of 23 sampled residents whose medical records were reviewed (Resident #21). The findings included:Resident #21 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD). A physician order dated 10/08/25 to change oxygen supplies every 7 days when oxygen is in use. Initial and date supplies. Every night shift, every Wednesday for oxygen cannula. Review of the Medication Administration Record (MAR) for November 2025 revealed Resident #21's oxygen was used every shift as ordered by the physician. Further review of the MAR revealed Resident #21's oxygen nasal cannula tubing was documented as changed on 11/05/25 and 11/12/25 by Nurse #4.An observation was conducted on 11/17/25 at 10:10 am of Resident #21. Resident #21 was observed in bed with oxygen at 2 liters via nasal cannula in place.…

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 staff and Dialysis Charge Nurse interviews, the facility failed to maintain ongoing communication with the dialysis treatment center for 1 of 1 resident reviewed for dialysis (Resident #18). The findings included: Resident #18 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD) and dependence on dialysis (treatment to filter wastes and water from the blood). Resident #18 had an active physician order dated 2/22/21 for dialysis on Monday, Wednesday, and Friday. Review of Resident #18's care plan last reviewed 7/09/24 revealed the need for dialysis related to renal failure with an intervention to communicate with the dialysis center by the dialysis communication form. Review of Resident #18's dialysis communication forms, located in the dialysis communication notebook at the nursing station, dated 8/01/24 through 9/09/24 revealed 8 of the 17 dialysis communications forms were not completed by the facility staff prior to dialysis for…

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 staff interviews, the facility failed to implement their infection prevention program policies and procedures when Nurse Aide (NA) #1 failed to perform hand hygiene after performing bathing and incontinence care for 1 of 2 residents observed for incontinence care (Resident #26). The findings included: The facility policy titled Infection Control, no date noted, revealed the purpose of the policy was to provide guidelines for the prevention of infection control in the facility. The policy stated in part that gloves were worn by all staff when providing care such as suctioning, bathing, care of perineal area, and wound care to prevent cross-contamination of infectious waste to hands. The facility policy titled Handwashing/Hand Hygiene dated 11/02/21 revealed hand hygiene was the primary means to prevent the spread of infections and that all staff shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy further stated that hand hygiene was to be…

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 staff interviews, the facility failed to 1) label and date opened items in 2 kitchen refrigerators (refrigerator #1 located in the stock room, and refrigerator #2 located near the tray line counter) and the kitchen wall freezer located in the stock room and 2) failed to remove expired items from the residents' refrigerator, failed to label and date food items in the residents' refrigerator, and keep 1 of 1 freezer used for residents' personal food items, free from ice build-up. The findings included: 1. During an observation of the kitchen on 5/22/23 at 10:14 am with the cook the following items were observed: a. The kitchen refrigerator #1, located in the stock room, was observed to have the following: 2 one-gallon containers of mayonnaise open and without a date, a container of tartar sauce open and without a date, a half empty jar of maraschino cherries open and without a date, and an open container of ranch dressing without a date. b. The kitchen wall freezer, located in the stock room, was observed to have 1 large clear plastic bag of frozen pizza…

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 staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification survey conducted on 1/07/22. This was for a recited deficiency on the current recertification and complaint survey in the area of food procurement, store, prepare, and serve in a sanitary manner. The continued failure during two surveys shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F812: Based on observations and staff interviews, the facility failed to 1) label and date opened items in 2 kitchen refrigerators (refrigerator #1 located in the stock room, and refrigerator #2 located near the tray line counter) and the kitchen wall freezer located in the stock room and 2) failed to remove expired items from the residents' refrigerator, failed to label and date food items in the residents' refrigerator, and keep 1 of 1 freezer used for residents' personal food items,…

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 staff interviews, the facility failed to complete a significant change assessment for a resident's admission to hospice services for 1 of 1 resident reviewed for hospice services. (Resident #151). The findings included: Resident #151 was admitted to the facility on [DATE] with diagnoses which included stroke, depressive disorder, and anxiety. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #151 had moderately impaired cognition and was not on hospice services. Review of the Hospice admission record revealed Resident #151 was admitted to hospice services on 4/26/23 with a diagnosis of stroke. Review of the Minimum Data Set (MDS) assessments revealed no significant change assessment was completed for Resident #151's admission to hospice services. An interview was conducted on 5/23/23 at 2:42 pm with the MDS Nurse who revealed she was new in the position, and she was not aware of Resident #151's admission to hospice services. She stated she was not notified…

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, observations, and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments for 4 of 24 sampled residents whose MDS were reviewed (Resident #3, Resident #18, Resident #23, and Resident #31). The findings included: 1. Resident # 3 was admitted to the facility on [DATE]. A physician order dated 8/31/23 for fentanyl patch (opioid medication for pain) 72 hour 50 micrograms/hour (mcg/hr). Apply 1 patch every 72 hours for pain remove per schedule. Review of the Medication Administration Record (MAR) for April 2023 revealed the fentanyl patch was administered as ordered. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #3 was not coded for opioid medication. During an interview on 5/24/23 at 12:48 pm the MDS Nurse revealed she was new to the position and was still learning and it was an oversight of the medication when she completed the annual assessment for Resident #3. An interview was conducted on 5/25/23 at 8:56 am with 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 staff interviews and record reviews, the facility failed to obtain a Level II Preadmission Screening and Resident Review (PASRR) after the initial approval for nursing home placement expired for 3 of 3 residents reviewed for PASRR (Resident #16, Resident #36, and Resident #35). The findings included: 1. Resident #16 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a disorder in the brain caused by a chemical imbalance in the blood). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had moderately impaired cognition. The MDS further revealed the Resident required extensive assistance from 2 staff members to complete activities of daily living and exhibited no behaviors during the assessment period. A review of the PASRR Level II Determination Notification document dated [DATE] revealed nursing facility placement was appropriate for a limited stay of no more than 30 days. The notification further explained if the resident was…

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, staff interviews, and Pharmacy Consultant interview, the facility failed to ensure Physician orders for as needed (PRN) psychotropic medications were time limited in duration for 1 of 1 resident reviewed for hospice services (Resident #151). The findings included: Resident #151 was admitted to the facility on [DATE] with diagnoses which included stroke, anxiety, and major depressive disorder. Resident #151 was discharged to the hospital on 4/17/23 and returned to the facility on 4/25/23 and was placed on hospice services. A physician order dated 4/25/23 for lorazepam (a medication used to treat anxiety) 1 milligram (mg) every four hours as needed (PRN) for agitation without a stop date. Record review of the Medication Administration Record (MAR) for April 2023 and May 2023 revealed Resident #151 had not been administered the lorazepam PRN. An interview was conducted on 5/23/23 at 3:06 pm with the Nurse Unit Manager who revealed she entered the lorazepam PRN order for Resident #151. She…

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.