Maybrook Hills Rehabilitation And Healthcare Cente

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of five residents reviewed (Resident 1). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant…

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 facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices for handling linen while providing care for two of 11 residents reviewed (Residents 10, 11). Findings include: The facility's infection control policy concerning handling of linen, dated May 8, 2024, revealed that staff is to handle soiled linen using standard precautions, such as wearing gloves. Observations on November 18, 2024, at 10:17 a.m. revealed that Nurse Aide 1 exited the room of Resident 11 carrying soiled laundry with her bare hands and placed them in the dirty linen bin in the hallway. Interview with Nurse Aide 1 on November 18, 2024, at 10:18 a.m. confirmed that she should wear gloves while handling soiled laundry. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated November 2, 2024, revealed that the resident was cognitively intact and required assistance from staff for daily care needs. Observations…

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 review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual Minimum Data Set assessments were completed in the required time frame for four of 57 residents reviewed (Residents 32, 128, 204, 225). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that an admission MDS assessment was to be completed no later than 14 days following admission, that the Assessment Reference Date (ARD - the last day of an assessment's look-back period) must be set within 366 days after the ARD of the previous comprehensive assessment, and that the assessment was to be completed no later than the ARD plus 14 calendar days. An admission MDS…

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 Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required timeframe for four of 57 residents reviewed (Residents 33, 147, 157, 159). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to be completed no later than the ARD plus 14 calendar days. A quarterly MDS assessment for Resident 33, with an ARD of June 12, 2024, was due to be completed by June 26, 2024, but was not signed as completed until June 27, 2024, which was 15 days from the ARD…

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 a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for eight of 57 residents reviewed (Residents 1, 3, 143, 148, 171, 182, 192, 194). Findings include: The Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that Section N0415F was to be coded (1) if an antibiotic medication was administered while a resident at the facility during the seven-day assessment period. Physician's orders for Resident 1, dated April 28, 2023, included an order for the resident to receive 1 gram of Hiprex (an antibiotic) twice a day for recurrent urinary tract infections. Review of the Medication Administration Record (MAR) for Resident 1, dated August 2024, revealed that the resident was administered 1 gram of Hiprex from August 1 through 28, 2024. An…

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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that medications were provided as ordered by the physician for two of 57 residents reviewed (Residents 2, 143). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 26, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included heart failure (a serious condition that occurs when the heart cannot pump enough blood and oxygen to the body's organs). A care plan for the resident, dated June 3, 2024, revealed that the resident was on an as needed diuretic (a drug that increases urine production, which helps the body get rid of extra salt and fluid) related to edema (swelling caused by fluid trapped in the body's tissues). Staff was to administer her medications as ordered. Physician's orders for Resident 2, dated June 1, 2024, included an order for staff to weigh the resident daily, and if the resident's weight was up two pounds 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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that enteral feedings (feeding through a tube inserted directly into the stomach) were administered in accordance with physician's orders and failed to ensure that residents who were receiving enteral feedings received appropriate treatment and services to prevent complications for two of 57 residents reviewed (Residents 20, 56). A facility policy for tube feeding, dated May 8, 2024, revealed that it is the policy and procedure to provide nourishment to the resident who is unable to obtain nourishment orally. The procedure for administering tube feeding includes to check for residual (the amount of gastric fluid in the stomach between feedings) by pulling back no more than 150 cubic centimeters (cc). Note the amount of residual if any. Return the gastric contents back into the stomach and clamp the gastric tube. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 20, dated…

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 facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices for cleaning durable medical equipment for two of 57 residents reviewed (Residents 47, 133), and for providing care for five of 57 residents reviewed (Residents 101, 152, 163, 184, 204). Findings include: Observations during the medication administration on August 27, 2024, at 8:37 a.m. revealed that Licensed Practical Nurse 5 obtained Resident 47's blood pressure prior to preparing the resident's medications. After Licensed Practical Nurse 5 administered Resident 47 her medications, she then went to Resident 133's room. Without cleaning the blood pressure cuff, she then obtained Resident 133's blood pressure prior to preparing his medications for administration. Interview with Licensed Practical Nurse 5 on August 27, 2024, at 9:03 a.m. confirmed that the blood pressure cuff should have been cleaned prior to obtaining Resident 133's blood pressure. Interview with the Assistant Director of Nursing on…

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 interviews with residents and staff, as well as observations, it was determined that the facility failed to ensure that residents could make choices about aspects of their lives that were significant to them, such as eating in the dining room with other residents, for nine of 57 residents reviewed (Residents 70, 72, 79, 125, 149, 151, 157, 162, 164). Findings include: Interview with Resident 72 on August 25, 2024, at 11:21 a.m. revealed that she likes to eat in the main dining room but has been unable to do so because the air conditioner is broken and the facility said that it would be too hot in there to have the dining room open. She indicated that the facility is waiting on a part to come to fix the air conditioner. During an group interview with Residents 70, 72, 79, 125, 149, 151, 157, 162, and 164 on August 26, 2024, at 2:04 p.m. the residents reported that they would like to eat in the main dining room, but they were told that they are unable to do so because the air conditioner is broken and the facility said that it would be too hot in there to have the dining room…

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 clinical record reviews and staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage, or failed to provide 48-hour advanced notice, for two 57 residents reviewed (Residents 201, 228). Findings include: Resident 201's medical record revealed that he began Medicare A services on March 1, 2024, and his last covered day was April 22, 2024. The medical record indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. The facility had no documented evidence that the resident was issued a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, or an Advance Beneficiary Notice (ABN) as required. A verbal notification was provided to the resident's responsible party on May 1, 2024, which was not 48 hours in advance. The ABN notice provided to the resident's responsible party did not include the items and services that are/are not covered under Medicaid…

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 clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative, in writing, regarding the reason for hospitalization for six of 57 residents reviewed (Residents 85, 96, 157, 171, 192, 218). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 85 revealed the resident was cognitively intact, was dependent on staff for personal care needs, had an indwelling catheter (thin tube inserted into the bladder to drain urine), and had diagnoses that included hemiplegia (paralysis of one side of the body) following a stroke. Nurses' notes for Resident 85, dated August 16, 2024, revealed that the resident was not looking good, was visibly shaking, and stated he felt cold. He required oxygen and had bleeding at his indwelling catheter site. The physician was notified, and the resident was sent to the emergency room for evaluation. The resident was admitted to the hospital with an elevated troponin level (blood test 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 review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive significant change Minimum Data Set assessments were completed in the required time frame for two of 57 residents reviewed (Residents 96, 171). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 20243, indicated that the Assessment Reference Date (ARD) was to be no later than the 14th calendar day after determination that a significant change in the resident's status occurred (determination date + 14 calendar days) and the significant change comprehensive MDS assessment was to be completed no later than the 14th calendar day after determination that significant a change in the resident's status occurred (determination date + 14 calendar days). A care plan for Resident 96,…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans to address individualized resident care needs for one of 57 residents reviewed (Resident 182). Findings include: The facility's policy regarding care plans, dated January 22, 2019, indicated that the facility would develop a written care plan that was individualized for each resident and address goals, actual and potential problems, needs, strengths, and individual preferences of the resident. An admission MDS assessment for Resident 182, dated June 30, 2024, revealed that the resident was cognitively impaired and required assistance from staff for daily care needs. Physician's orders for Resident 182, dated June 25, 2024, included an order for the resident to use a CPAP (continuous positive airway pressure) at bedtime for sleep apnea (disorder that causes breathing to stop or become shallow during sleep). Review of the Medication Administration Record (MAR) for Resident 182, dated August 2024, revealed that the resident used a CPAP device…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for two of 57 residents reviewed (Residents 125, 191). Findings include: The facility's policy regarding care plans, dated May 8, 2024, indicated that the facility would develop a written care plan that was individualized for each resident and address goals, actual and potential problems, needs, strengths, and individual preferences of the resident. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 125, dated June 2, 2024, revealed that she was cognitively intact, was dependent on staff for personal hygiene needs, and had diagnosis that included having a left hip fracture. The care plan for Resident 125, dated July 12, 2024, indicated that the resident was receiving anticoagulant (blood thinner) therapy for a diagnosis of atrial fibrillation (irregular heartbeat). Review of the Medication…

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 clinical records and the facility's investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained as free from falls as possible and failed to develop and implement interventions to prevent falls for one of 57 residents reviewed (Resident 165) who had a history of falling. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 165, dated August 6, 2024, revealed that the resident was cognitively impaired, required extensive assistance for daily care needs and assistance for transfers, had a history of falls, and had diagnoses that included lower back pain, difficulty walking, and dementia. A nursing note for Resident 165, dated August 22, 2024, at 8:20 p.m., revealed that the resident had a fall out of her wheelchair to the side of her bed. Resident 165 was assessed and had a red, swollen right wrist with no injuries as evidenced by an X-ray on August 22, 2024. An incident report for 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.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 57 residents reviewed (Resident 46). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated July 3, 2024, indicated that the resident was moderately cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included depression and PTSD. A review of Resident 43's care plan, dated July 9, 2024, indicated that the resident had PTSD and depression. There was no documented evidence the facility identified Resident 46's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring. Interview 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.

Based on a list of nurse aides provided by the facility and their personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on the hire dates for three of three nurse aides reviewed (Nurse Aide 1, Nurse Aide 2, Nurse Aide 3). Findings include: A review of the personnel file for Nurse Aide 1 revealed a hire date of August 11, 1998, with a performance evaluation completed on August 12, 2024. However, there was no documented evidence that her annual performance evaluation was completed as required in August 2023. A review of the personnel file for Nurse Aide 2 revealed a hire date of July 2, 2008, with a performance evaluation completed on June 28, 2024. However, there was no documented evidence that his annual performance evaluation was completed as required in July 2023. A review of the personnel file for Nurse Aide 3 revealed a hire date of August 12, 2018, with a performance evaluation completed on August 12, 2024. However, there was no documented evidence that her annual…

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 policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that controlled medications (drugs with the potential to be abused) were properly secured in the medication cart for one of 57 residents reviewed (Resident 14) and failed to ensure that medications were appropriately labeled for one of 57 residents reviewed (Resident 47). The facility's policy for medication storage dated May 8, 2024, included that all controlled drugs are stored under double-lock and key. Physician's orders for Resident 14, dated August 25, 2024, included an order to give the resident 0.5 milligrams (mg) of Clonazepam every eight hours for anxiety. Observations of the [NAME] Hall medication cart on August 27, 2024, at 8:39 a.m. revealed that the second drawer from the top of the medication cart had one medicine cup in it containing one round yellow pill. There was no name or label attached to the medication or cup. An interview with Licensed Practical Nurse 4 at the time of the observation revealed that the medication was a controlled…

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 policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions and failed to ensure that dietary staff wore appropriate hair and beard coverings in the kitchen. Findings include: The facility's policy regarding hair net policy for nursing home kitchen staff, dated May 8, 2024, revealed that kitchen staff should maintain personal hygiene. Hair should be clean and neatly tied or pinned back under a hair net. Facial hair, such as beards, must also be covered with a beard net. Observations in the main kitchen during the lunch meal tray line on August 27, 2024, at 11:45 a.m. revealed that Dietary Worker 6, Dietary Worker 7, Dietary Worker 8, Dietary Worker 9, Dietary Worker 10, and Dietary Worker 11 had beards that were not covered with beard nets/covers during tray line. Dietary Worker 12 and Dietary Worker 13 did not have their hair completely under a hair net during food preparation. Interview with the Dietary Manager on August 27, 2024, at 11:47 a.m. confirmed that dietary…

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 clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 57 residents reviewed (Resident 225). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 225, dated August 15, 2024, indicated that the resident was understood, could understand, was cognitively intact, required assistance with daily care tasks, and required hemodialysis treatments (procedure that removes waste and excess fluid from the blood when the kidneys are unable to do so). A care plan for Resident 225, dated August 9, 2024, indicated that she was at nutritional risk due to the need for more protein due to end-stage renal disease and hemodialysis. Resident 225 had an intervention to monitor, record, and report any muscle wasting or significant weight loss to the physician. Physician's order for Resident 225, dated August 9, 2024 indicated that the resident was ordered…

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 clinical records, as well as staff interviews, it was determined that the facility failed to obtain the required information from the contracted hospice provider for one of 57 residents reviewed (Resident 128). Findings include: The hospice contract for Family Hospice dated, January 1, 2020, revealed that the agency shall provide the facility with a copy for each hospice patient of the most recent plan of care specific to each patient, the physician certification and recertification of the terminal illness specific to each patient. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs)for Resident 128, dated July 10, 2024, revealed that the resident was rarely understood and had a memory problem, was dependent on staff for her daily care needs, and had a diagnosis of dementia. A care plan for Resident 128, dated August 2, 2024, indicated that the resident was receiving hospice care. A hospice Election of Benefit document (a form signed to indicate that the individual waives all rights to traditional Medicare…

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's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending October 26, 2023, and a complaint investigation survey ending April 16, 2024, revealed that the facility developed plans of correction that included quality assurance systems with audits to ensure that the facility maintained compliance with cited nursing home regulations. The results of the audits were to be reported to the QAPI committee for review. The results of the current survey, ending August 28, 2024, identified repeated deficiencies regarding timely completion of comprehensive assessments, accuracy of assessments, development of comprehensive care plans,…

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 clinical records and staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in a significant medication error for one of five residents reviewed (Resident 2). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 3, 2024, indicated that the resident was cognitively impaired, received a diuretic (water pill), and had diagnoses that included heart failure. A nursing note, dated May 22, 2024, revealed that laboratory results were reviewed with the Certified Registered Nurse Practitioner (CRNP - a registered nurse who has advanced education and clinical training in a health care specialty area), and new orders were received for 40 milligrams (mg) of Torsemide (water pill) twice a day for two days and 20 milliequivalents of potassium chloride (supplement) daily for three days and obtain a basic metabolic panel (BMP - blood test that checks the levels of different substances in your blood) on May 24,…

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 Pennsylvania's Nursing Practice Act, job descriptions, and clinical records, as well as staff interviews, it was determined that the facility failed to correctly transcribe physician's orders for one of five residents reviewed (Resident 2). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A job description for registered nurses, undated, indicated that the registered nurse was to ensure that the highest degree of quality care was maintained at all times and was to provide direct nursing care as needed. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 3, 2024, indicated 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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that oxygen was provided as ordered by the physician for one of five residents reviewed (Resident 1). Findings include: The facility's policy regarding oxygen use, dated May 8, 2024, indicated that the facility was to provide oxygen as ordered by the physician. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 4, 2024, revealed that the resident was cognitively intact and received oxygen. A care plan for the resident, dated February 22, 2024, revealed that the resident received oxygen therapy. Physician's orders, dated July 10, 2024, included an order for the resident to receive oxygen at two liters per minute (lpm) every shift for hypoxia (low levels of oxygen in your body tissues). Observations of Resident 1 on August 7, 2024, at 3:11 p.m. and 3:15 p.m. revealed that the resident had oxygen in use via a concentrator (electrical machine…

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 policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that staff reported an allegation of verbal abuse in a timely manner for one of six residents reviewed (Resident 2). Findings include: The facility's policy regarding abuse, dated May 8, 2024, indicated that each resident had the right to be free from mistreatment, neglect, and misappropriation of property. No one may subject residents to abuse including, but not limited to facility staff, other residents, consultants, volunteers, staff or other agencies serving the residents, family members or legal guardians, friends and other individuals. Observances, complaints or evidence of alleged abuse, neglect and/or mistreatment are thoroughly investigated and reported to the appropriate parties. The definition of verbal abuse meant the use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families or within hearing distance regardless of their age, ability to…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address resident care needs for two of nine residents reviewed (Residents 3, 7). Findings include: The facility's policy regarding care plans, dated February 21, 2024, revealed that the interdisciplinary team will develop and implement the comprehensive care plan within 21 days of admission. The comprehensive care plan will address resident goals, actual and potential problems, needs, strengths, and individual preferences of the resident. An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 3, dated March 1, 2024, indicated that he was cognitively intact and had ointments/medications applied to areas other than his feet. An admission nursing assessment, dated February 23, 2024, revealed that Resident 3 had an open area on his left shin that measured 2.0 x 2.0 centimeters (cm). 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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that dialysis residents had an active physician's order to attend dialysis and failed to obtain physician's orders for the care and monitoring of dialysis sites for one of nine residents reviewed (Resident 7). Findings include: A nursing note for Resident 7, dated March 20, 2024, revealed that the resident was admitted to the facility from the hospital with a diagnosis of End Stage Renal Disease (ESRD - permanent kidney failure that requires a regular course of dialysis or a kidney transplant) requiring dialysis (mechanical cleansing of the blood for a person whose kidneys are not functioning normally) and had a right subclavian dialysis catheter (a tube inserted into a vein in the chest to provide access for dialysis). Dialysis communication sheets for Resident 7 revealed that the resident received dialysis March 22, 25, and 27, 2024, and April 1, 3, 5, 8, and 12, 2024. However, there was no documented evidence in Resident 7's clinical record that physician's orders were…

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 Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of nine residents reviewed (Residents 3, 7). Findings include: The Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that Section N0415J (Hypoglycemic Medications - medications that lower blood sugars) was to be checked if the resident was taking any medications by pharmalogical classification, not how it was used, during the last seven days, or since admission/entry or reentry if less than seven days. Physician's orders for Resident 3, dated February 23, 2024, included orders for the resident to receive 1000 milligrams (mg) of Metformin HCl (hypoglycemic medication) with meals for diabetes and 2 mg of Glimepiride (hypoglycemic medication) with meals for diabetes.…

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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide care for wounds in accordance with professional standards of practice by failing to follow recommendations from wound consultations for one of nine residents reviewed (Resident 3), and failed to ensure that the physician was notified about elevated blood sugar results as ordered for one of nine residents reviewed (Resident 7). Findings include: The facility's policy regarding wound care, dated March 14, 2024, indicated that the facility was to promote wound healing and prevent infections. An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 3, dated March 1, 2024, indicated that he was cognitively intact and had ointments/medications applied to areas other than his feet. An admission nursing assessment, dated February 23, 2024, revealed Resident 3 had an open area on his left shin that measured 2.0 x 2.0 centimeters (cm). Physician's orders, dated February 23,…

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 facility policy, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for two of nine residents reviewed (Residents 2, 9). Findings include: A facility policy regarding nursing documentation, dated February 21, 2024, revealed that the facility documents by exception and all documentation confirms that care was provided. Staff were responsible for documenting acts as proof care was provided. All documentation was to be completed in the electronic record Point Click Care (PCC). All events such as falls, skin abnormalities, etc. should be documented. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 15, 2024, indicated that the resident was understood, could understand, was cognitively impaired, required assistance with daily care tasks, and had a history of falls. A fall care plan for Resident 2, dated November 15, 2021, revealed that 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.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that laboratory specimens were obtained as ordered by the physician for one of nine residents reviewed (Resident 2). Findings include: Physician's orders for Resident 2, dated November 18, 2023, included an order for the resident to have a urinalysis and culture and sensitivity obtained (urine tests to check for an infection). A nursing note for Resident 2, dated November 18, 2023, revealed that the resident refused to have a catheter placed (an invasive procedure to collect urine from the bladder) for a urine specimen and would urinate using the toilet. A nursing note, dated November 25, 2023, indicated that Resident 2's family was still requesting that the resident have her urine checked for infection as per the physician's order from November 18, 2023. A nursing note for Resident 2, dated December 8, 2023, indicated that the family continued to request that the urinalysis and culture and sensitivity be completed. Physician's orders for Resident 2, dated December 8, 2023,…

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 review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual Minimum Data Set assessments were completed in the required timeframe for seven of 58 residents reviewed (Residents 51, 80, 156, 168, 170, 183, 191 ). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that an admission MDS assessment was to be completed no later than 14 days following admission. An admission MDS assessment for Resident 51 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on September 15, 2023, which was 16 days after admission. An admission MDS assessment 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for nine of 58 residents reviewed (Residents 48, 57, 79, 113, 117, 126, 148, 155, 192). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that Section N0410D (hypnotic medication) was to be coded with the number of days the resident received a hypnotic medication during the seven-day assessment period. Physician's orders for Resident 48, dated September 5, 2023, included an order for the resident to receive 15 milligrams (mg) of Restoril every 24 hours at bedtime as needed for insomnia. The resident's Medication Administration Record (MAR) for September 2023 revealed that the resident received Restoril…

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 clinical records and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address care needs for four of 58 residents reviewed (Resident 5, 45, 67, 150). Findings include: The facility's policy regarding care plan development, dated June 26, 2023, revealed that it is the policy of this facility to develop and review an interdisciplinary care plan to meet resident care and educational needs. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated July 6, 2023, revealed that the resident was cognitively intact and required minimal to moderate assistance with daily care needs. Physician's orders, dated October 9, 2023, for Resident 5, included an order for contact precautions. A nursing note, dated September 13, 2023, at 2:05 p.m., revealed that Resident 5 had a biopsy (skin sample for testing) of a rash, and there was a new order of contact precautions until the rash was resolved. A…

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 clinical records and staff interviews, it was determined that the facility failed to ensure that physician's orders regarding notification of the physician for blood sugar results were followed for one of 58 residents reviewed (Resident 48). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 48, dated September 11, 2023, revealed that the resident was cognitively intact, received insulin (medication that lowers blood sugar levels), and had diagnoses that included diabetes. Physician's orders for Resident 48, dated September 5, 2023, included an order for the resident to have his blood sugar checked before meals and at bedtime, and the physician was to be notified if the blood sugar was less than 70 milligrams/deciliter (mg/dL) or greater than 400 (mg/dL). Resident 48's Medication Administration Record (MAR's) for September and October 2023 revealed that the residents blood sugar results were less than 70 mg/dL at 6:00 a.m. on September 16 and October 21 and 29,…

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 review of package inserts, as well as observations and staff interviews, it was determined that the facility failed to discard expired medical supplies in one out of three medication rooms reviewed (D1) and one out of one treatment rooms reviewed. Findings include: The facility had no policy relating to the use of outdated medical supplies. Per the package insert for the blood collection tubes, they expire on the last day of the month and year indicated. Observations in the phlebotomy basket (basket holding blood collection tubing and tubes) in the D1 medication room on [DATE], at 1:28 p.m. revealed that there were 33 blood collection tubes that were expired. There were nine gold-top tubes that expired [DATE]; 11 blue-top tubes that expired [DATE]; six red-top tubes that expired [DATE]; two green-top tubes that expired [DATE]; two lavender-top tubes that expired [DATE]; and three dark purple-top tubes that expired [DATE]. Interview with Licensed Practical Nurse 5 and Registered Nurse 6 on [DATE], at…

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 facility's policies, observations, and resident and staff interviews, it was determined that the facility failed to serve food items that were palatable and at proper temperatures. Findings include: The facility's policy regarding dietary food temperatures, dated June 26, 2023, indicated that temperatures are to be recorded and taken randomly throughout the meal service. Hot foods shall be held at 140 degrees Fahrenheit (F) or above until served and cold foods should be held at 41 degrees F or below. Interviews with Residents 42, 106, 127, 148, and 195 on October 23, 2023, during the initial survey sampling process, revealed that the food served by the facility at meal times was not served hot enough, and that their meals arrive with food being cold. Interview with Residents 8, 42, 48, 73, 85, 157, and 160 during a group meeting on October 24, 2023, at 1:15 p.m. revealed that the food served by the facility at meal times was not served hot enough, and that their meals arrive in styrofoam containers and the food is cold. Observations of the lunch meal service 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 and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions. Findings include: Observations in the main kitchen on October 23, 2023, at 9:30 a.m. revealed a large air vent in the ceiling between a prep table, the walk-in-cooler, and walk-in-freezer that had an accumulation of dust that extended out onto the ceiling tiles surrounding the air vent. There was a large air vent in the ceiling between the steam tables and ovens that had an accumulation of dust that extended out onto the ceiling tiles surrounding the air vent, and there was a large air vent in the ceiling between the Dietary Director's office and the end of tray line that had an accumulation of dust that extended out onto the ceiling tiles surrounding the air vent. Observations in the main kitchen on October 24, 2023, at 11:10 a.m. revealed that the large air vent in the ceiling between a prep table, the walk-in-cooler, and walk-in-freezer had the same accumulation of dust that extended out onto the ceiling tiles surrounding the air vent.…

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's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) surveys ending October 20, 2022, and May 8, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending October 26, 2023, identified repeated deficiencies related to a failure to complete MDS assessments accurately, failure to revise a resident's care plan to include current interventions, failure to maintain compliance with the regulation regarding proper storage and labeling of medications, and failure to serve palatable food at appropriate…

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 review of manufacturer's instructions and information provided by the facility, as well as observations and resident and staff interviews, it was determined that the facility failed to maintain an effective preventative maintenance program for the walk-in-freezer and failed to maintain the dish machine in proper working condition in the Main Kitchen, taking away the residents' right to have a homelike environment. Findings include: Manufacturer's directions for use for the [NAME] Duracool walk-in-freezer, dated February 5, 1997, revealed that the owner/user is responsible for the proper upkeep of a [NAME] walk-in. Simple procedures of cleanliness and preventative maintenance will ensure many years of trouble-free service. The owner was to maintain unrestricted air flow across the condensing unit and be sure the condenser coil was kept free of dirt at inlet (behind usually) and outlet (in front usually). Periodically check the heater cable in the freezer door for function. Periodically check the function…

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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents' baseline care plans included information regarding their immediate care needs for one of 58 residents reviewed (Resident 195). Findings include: An entry tracking form for Resident 195, dated October 16, 2023, revealed that the resident was admitted on [DATE]. Physician's orders for Resident 195, dated October 16, 2023, included orders for the resident to receive 800-160 milligrams (mg) of sulfamethoxazole-trimethoprim (antibiotic) twice a day for seven days for a urinary tract infection, and 30 mg of duloxetine HCl (antidepressant) twice a day for nerve pain. There was no documented evidence that a baseline care plan (developed within 48 hours of a resident's admission and must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission) included information regarding the resident's care needs related to receiving an antibiotic…

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for three of 58 residents reviewed (Residents 31, 145, 152). Findings include: The facility's policy regarding care planning, dated June 26, 2023, indicated that a resident's care plan was to be reviewed and revised as needed. A diagnosis record for Resident 31, dated June 24, 2022, revealed that the resident had diagnoses that included hypertension and myocardial infarcation. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated August 12, 2023, indicated that the resident was cognitively intact and required extensive assistance from staff for bed mobility and transfers. Physician's orders for Resident 31, dated July 4, 2023, included an order for the resident to receive acyclovir (a medication to treat infections) 200 mg two times a day for five days for a rash. Nursing clinical notes, dated July 10,…

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 manufacturer's instructions and clinical records, as well as resident, family, and staff interviews, it was determined that the facility failed to ensure that residents had proper assistive devices to maintain adequate hearing for one of 58 residents reviewed (Resident 92). Findings include: Manufacturer's instructions for the hearing aides, dated May 2023, indicated that if the battery door of the hearing aide was difficult to close, check that the battery was inserted correctly and that the flat side was facing upwards. If the battery was not inserted correctly, the hearing aide would not work and the battery door could be damaged. The flat side was marked with a + symbol either on the sticker or on the battery. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 92, dated September 14, 2023, revealed that the resident was cognitively intact, required minimal assistance with daily care needs, and had minimal difficulty with hearing. Resident 92's care plan, dated May 17, 2022, revealed 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 review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate that was less than five percent. Findings include: Observations during medication administration on October 25, 2023, revealed that two medication administration errors were made during 30 opportunities for error, resulting in a medication administration error rate of 6.66 percent. Physician's orders for Resident 165, dated October 27, 2022, included an order for the resident to receive one 2.5 milligram (mg) tablet of Midodrine (used to treat low blood pressure) three times per day. Staff was to monitor the resident's blood pressure one hour prior to administration and one hour after administration. Staff was to hold the medication if the resident's blood pressure was 160/90 millimeters of mercury (mmHg) or above. Physician's orders for Resident 165, dated July 17, 2023, included an order for staff to check the resident's blood pressure one hour prior to the administration of the Midodrine and one hour after…

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 clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 58 residents reviewed (Resident 45). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 45, dated August 6, 2023, revealed that the resident was cognitively impaired, required extensive assist for daily care needs, and had diagnoses that included Alzheimer's dementia. Physician's orders for Resident 45, dated September 28, 2023, included an order to change and date oxygen tubing and set-up including foam ear protectors, remove concentrator filter, cleanse with soap and water, rinse, towel dry and replace on night shift every Wednesday. Review of the Treatment Administration Record (TAR) for Resident 45 revealed no documented evidence that the oxygen tubing, ear protectors, and concentrator filter was changed per physician orders. An interview with the Director of Nursing on October 26, 2023,…

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.