Quality Life Services - Apollo

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for three of nine residents (Residents R25, R105, and R186). Findings include: Review of facility policy Physician Orders dated 6/3/24, and last reviewed 4/17/25, indicated physician orders are followed in accordance with good nursing principles and practices. The purpose is to ensure that the residents receive all medications and treatments that are ordered by the physician in a timely manner. Review of facility policy Bowel Management dated 4/17/25, indicated the standard regimen for bowel management will be followed for a resident who experiences alteration in bowel elimination. The purpose is to provide regularity of bowel movement and prevent constipation. On the 3rd day without a bowel movement, two tablets of Senna must be administered by mouth. On the 4th day, if Senna is ineffective, give Bisacodyl…

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 facility document, resident record review, and staff interviews, it was determined that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for four of four residents (Resident R12, R57, R58, and R116). Findings include: Review of facility job description Social Worker, indicated that the Social Worker will carry out social evaluations and plan interventions based on evaluation findings, and counsel residents/ family/caregivers as needed in relationship to stress and other identified coping difficulties. Ensure compliance with all Federal, State, and local regulations. Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/15/25, indicated diagnoses of high blood pressure, Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty…

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 facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in two of two medications rooms (Angel Wing Medication Room and GRU Medication Room), and two of three medication carts (Angel Wing Back Medication Cart and GRU Back Hall Medication Cart). Findings include: Review of facility policy Storage of Medications dated [DATE], indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Medications requiring refrigeration are kept in a refrigerator at temperatures between 2°C (36°F) and 8°C (46°F) with a thermometer to allow temperature monitoring. The facility shoulder maintain a temperature log in the storage area to record temperatures at least once a day. Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date. When the original seal of a manufacturer's container or vial 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 facility policy, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of four residents (Resident R25). Findings include: Review of facility policy Indwelling Urinary Catheter dated 4/17/25, indicated the catheter bag should have a privacy cover applied at all times unless it has one built in by the manufacturer. Review of the clinical record indicated Resident R25 was admitted to the facility on [DATE]. Review of Resident R25's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/5/25, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and respiratory failure (a condition where the lungs cannot get enough oxygen into the blood). Review of Resident R25's care plan dated 6/19/24, indicated the resident has an indwelling urinary catheter with an intervention of position catheter bag 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 review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for two of five residents (Residents R35 and R79). Findings include: Review of facility policy Call Lights dated 4/17/25, indicated to assure resident has call light or alternative communication device within reach at all times when unattended. Review of the clinical record indicated Resident R35 was admitted to the facility on [DATE]. Review of Resident R35's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/7/25, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and need for assistance with personal care. During an observation on 5/19/25, at 10:02 a.m. Resident R35's call bell was observing hanging from the wall unit at the head of the bed, out of the resident's reach. During an interview on 5/19/25, at 10:23 a.m. Licensed Practical Nurse (LPN) Employee E1…

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 facility policy, observation, clinical record review and staff interview it was determined that the facility failed to obtain a physician order, develop a resident centered care plan, and determine resident safety for the placement of a bed against the wall for two of two residents (Resident R103, and R106). Findings include: Review of the facility policy Physical Restraint dated 4/17/25, indicated each resident is to attain and maintain his/her highest practical well-being in an environment that prohibits the use of restraints for discipline or convenience and limits use of restraints use to circumstances in which the resident has medical symptoms that warrant the use of restraint. The use of restraint will be a last resort alternative intervention. Review of Resident R103's clinical record indicated an admission date of 3/17/25. Review of resident 103's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/8/25, indicated the diagnosis of dementia (a group of symptoms…

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, clinical records, and staff interview, it was determined that the facility failed to make certain that that quarterly Minimum Data Set assessments were completed within the required time frame for one of six residents (Resident R73). Findings include: Review of 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 2024, indicated that quarterly MDS assessments were to be completed no later than 14 calendar days after the Assessment Reference Date (ARD). Resident R73 had a quarterly ARD of 12/24/24, and was due to be completed 1/7/25. The MDS was signed as completed on 1/15/25, eight days after the due date. During an interview on 5/21/25, at 12:33 p.m. Registered Nurse Assessment Coordinator Employee E8 confirmed that the facility failed to make certain that quarterly Minimum Data Set assessments were completed…

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 facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for two of three residents (Residents R12 and R22). Findings include: Review of facility policy Comprehensive Care Plan dated 6/3/24, and last reviewed 4/17/25, indicated to allow each individual or individual's representative to make informed choices about accepting or declining care and treatment. The care plan reflects an individual's choices, either as offered by the individual directly or via a valid advance directive, or based on a decision made by the individual's representative in accordance with state law. Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/15/25, indicated diagnoses of high blood pressure, Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty…

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 records and staff interview, it was determined that the facility failed to revise a care plan to accurately reflect the current status for one of six residents (Resident R65). Findings include: Review of clinical record indicated Resident R65 was admitted to the facility on [DATE], with diagnoses that included adult failure to thrive, chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs resulting in inflammation inside the airways that limit airflow into and out of the lungs) and asthma. Review of Resident R65's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 5/5/25, indicated the diagnoses remain current. Review of Resident R65's physician orders dated 3/23/25 Regular, 7EC (Easy to Chew) diet, Allergic to milk and strawberries. Review of Resident R65's Resident Care Plan Summary Report (report nurse aides used to know what kind of care to provide) dated 2/24/25, revealed no allergy. During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, job descriptions, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice by failing to administer medications to the correct resident for one of five residents (Resident R182). Findings include: Review of facility policy Specific Medication Administration Procedures dated 4/17/25, indicated to review the 5 Rights of medication administration (right medication, right patient, right dose, right route, right time) three times. Identify the resident using two identification methods before administering medication (e.g., photo plus verbal confirmation of last name, photo and confirmation by family member, etc.) Review of the facility Licensed Practical Nurse (LPN) job description indicated the LPN administers medications to residents in an accurate, timely manner. Review of the clinical record indicated Resident R182 was admitted to the facility on [DATE]. Review of 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 a resident's interview, clinical record review and review of the facility policy, it was determined that the facility failed to provide supervision with meals as ordered for one of three residents (Resident R23). Finding include: Review of the facility policy titled, Physician Orders last reviewed 4/17/25, stated physician orders are followed in accordance with good nursing principles and practices. Review of Resident R23's admission record indicated she was admitted to the facility on [DATE], with diagnoses of cerebral infarction (occurs when blood flow to the brain is cut off) and dysphagia (difficulty swallowing), and abnormal posture. Review of Resident R23's physician order dated 8/23/25, revealed the resident requires direct supervision with meals for assistance with feeding. The resident enjoys eating in the dining room. Review of Resident R23's care plan dated 7/29/24, revised 5/15/25, indicated the resident needs assisted with meals but is resistive to others helping him eat. Review of 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 review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one of two residents (Residents R116). Findings include: Review of facility policy Restorative Nursing Standard dated 4/17/25, indicated that the facility provides a Restorative Nursing program with interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. The Restorative Nursing Coordinator facilitates communication between the interdisciplinary team and manages the Restorative Nursing program. Categories of Restorative Nursing programs include splint or brace assistance. A physician's order is obtained and entered into electronic health record. Document 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 review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of two residents (R79). Findings include: Review of facility policy Basic Guidelines for Enteral Feeding dated 4/17/25, indicated basic guidelines for enteral feeding will be followed by all staff delivering care to enterally fed individuals. Review of the clinical record indicated Resident R79 was admitted to the facility on [DATE]. Review of Resident R79's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/25/25, indicated diagnoses of anemia (too little iron in the blood), hemiplegia (paralysis on one side of the body), and muscle weakness. Review of a physician order dated 4/21/25, indicated two times a day for nutrition Jevity 1.5 (a tube feeding formula) via…

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 facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of four residents (Resident R25). Findings include: Review of facility policy Oxygen Therapy via Nasal Cannula dated 4/17/25, indicated to replace cannula every seven days, date and store in plastic bag when not in use. Review of facility policy Small Volume Nebulizer dated 4/17/25, indicated to ensure equipment is dry, not damp, and place in storage bag labeled with resident's name and date equipment was used. Replace equipment every seven days. Date connecting tubing. Replace every seven days. Review of the clinical record indicated Resident R25 was admitted to the facility on [DATE]. Review of Resident R25's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/5/25, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time),…

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 review, facility policy and interviews with staff, it was determined that the facility failed to ensure the physician reviewed the resident's total program of care for one of five residents (Resident R105). Findings include: Review of the facility policy Administering Medications last reviewed 12/9/24, revealed medications are administered vin a safe and timely manner, and as prescribe. If dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associate with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. Review of the clinical record indicated Resident R105 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses of high blood pressure, phantom limb pain syndrome with pain, 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.

Based on review of personnel records, and staff interview it was determined that the facility failed to complete annual performance evaluations for three out of five nurse aides (NA Employee E13, E14 and E15). Findings include: Review of personnel files reviewed that Nurse Aide Employee E15 start date was 5/28/97, last performance evaluation was completed 10/22-10/23. Review of personnel files revealed that Nurse Aide Employee E13 last hire date was 8/17/20, last performance evaluation was completed 10/22-10/23. Review of personnel files revealed that Nurse Aide Employee E14 last hire date was 7/19/21, last performance evaluation was completed 10/22-10/23. During an interview on 5/21/24, at 12:45 p.m. Human Resources Employee E12 confirmed that the facility does not have up to date performance appraisals completed on NA Employee E13, E14 and E15. 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development. 28 Pa Code: 201.14 (a) Responsibility of licensee.

Based on a review of four-week cycle menu, and staff interviews, it was determined that the facility failed to have a registered dietitian review and approve the menu and nutritional substitutes prior to implementation for one out three meals served on 4/25/25 (lunch). Findings include: During an interview on 5/19/25, at 2:18 p.m. Dietary Manager (DM) Employee E16 stated that the facility prepared a special meal on 4/25/25, that was designed to enter a competition amongst sister facilities for a cook-off. DM Employee E16 stated that she then adapted this recipe for Braised Beef Tips to be served to the residents for lunch on 4/25/25. Review of the four-week menu cycle failed to indicate that the lunch meal for 4/25/25, included a signature of approval from a registered dietitian. During an interview on 5/21/25, at 1:20 p.m. Registered Dietitian Employee E17 confirmed that the facility failed to acquired approval for the special menu served on lunch 4/25/25, from a Registered Dietitian prior to serving. 28 Pa Code: 211.6(a) Dietary services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for one of three residents (Resident R38). Findings include: Review of facility policy Hospice Referral dated 4/17/25, indicated that a hospice referral will be initiated in accordance with resident and family wishes. Care will be coordinated with the resident's physician, pharmacy, and responsible party as appropriate. Review of the clinical record indicated Resident R38 was admitted to the facility on [DATE]. Review of Resident R38's MDS (MDS-Minimum Data Set assessment: periodic assessment of resident care needs)dated 3/24/25, indicated diagnoses of epilepsy (brain condition that causes reoccurring seizures), diabetes mellitus (metabolic disorder in which the body has high sugar levels for prolonged periods of time), and major depressive disorder (mental health…

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 facility policy, resident clinical records, facility documents, and staff interviews, it was determined that the facility failed to timely enter an order for isolation for one of nine residents (Resident R68) and have a surveillance plan for tracking, and monitoring residents who tested negative for Influenza during an outbreak for two of ten months (February 2025 to March 2025). Finding include: Review of the Respiratory Virus Outbreak Toolkit dated 11/14/24, indicated a case-line listing is designed to collect information about all ill cases (residents and staff) during an outbreak in a long-term care facility. It was indicated upon identification of an outbreak, use this template to collect and organize information on cases. The type of test ordered and if pathogens were detected must be recorded. Review of the clinical record indicated Resident R68 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of influenza, anxiety, and depression. Review of 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 review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (leaving an area without permission) for one of 16 residents (Resident R1), and failed to make certain each resident received adequate monitoring of an elopement prevention device for one of 16 residents (Resident R2). Findings include: Review of facility policy Elopement Prevention last reviewed 6/3/24, indicated that the facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. Should the resident's behavior warrant elopement prevention measures, a comprehensive elopement prevention plan will be documented as part of the care plan. Staff observations will be noted during the resident's stay and modifications will be made to the care plan and prevention techniques. If a Wanderguard (a device applied to the resident 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 observations, resident interview, and staff interview it was determined that the facility failed to have complete contact information for State Long-Term Care Ombudsman program posted at the facility. Findings include: During an interview on 3/18/25, at 11:32 a.m. Resident R2 asked State Agency for email of the Ombudsman, as it was not listed on the Ombudsman poster in the hallway. During an observation in Buttercup Hallway there was a poster with Ombudsman contact information which only consisted of the phone number, and did not have name, address, or email address listed. During an observation and interview on 3/18/24, at 2:27 p.m. The Nursing Home Administrator confirmed that the facility failed post the Ombudsman's name, address, and email address as required. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(b)(3) Management.

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of four units (Geriatric Rehabilitation Unit Back Medication Cart). Findings include: Review of facility policy HIPAA/HITECH Administrative Policy dated 6/3/24, indicated the facility is to protect residents' privacy rights and their individually identifiable health information as required by the Health Insurance Portability and Accountability Act (HIPAA), Standards for Privacy of Individually Identifiable Health Information, 45 CRF Parts 160 and 164, the Health Information Technology for Economic and Clinical Health Act (HITECH) and all Federal regulations and interpretive guidelines promulgated thereunder. During an observation on 3/18/25, at 2:05: p.m. the Geriatric Rehabilitation Unit Back Medication Cart beside the nurse's station, was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop a baseline care plan for one of three residents (Resident R1). Findings include: Review of facility policy Care Plan and Interdisciplinary Care Conferences dated 6/3/24, indicated that an individualized, interdisciplinary care plan is initiated within 24 hours for each resident as part of the care delivery process. Review of Resident R1's clinical record revealed hospital documentation dated 11/6/24, that stated that tracheostomy is present. Review of Resident R1's clinical record revealed that resident was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/20/24, indicated diagnoses of cancer (uncontrolled growth and spread of abnormal cells), malnutrition (lack of nutrients to the body), and muscle weakness. Review of Resident R1's clinical record revealed a physician's order dated 11/15/25, to provide…

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 facility policy, clinical record review, and staff interviews, it was determined that the facility failed to obtain an order for a resident with a tracheostomy (a procedure to help air and oxygen each the lungs by creating an opening into the windpipe from outside the neck), to ensure proper tracheostomy care for one of three residents (Resident R1). Findings include: Review of facility policy Tracheostomy Care dated 6/3/24, indicated that tracheostomy care is performed a minimum of one time per shift. Review of Resident R1's clinical record revealed hospital documentation dated 11/6/24, that stated that tracheostomy is present. Review of Resident R1's clinical record revealed that resident was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/20/24, indicated diagnoses of cancer (uncontrolled growth and spread of abnormal cells), malnutrition (lack of nutrients to the body), and muscle weakness. Review of 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 clinical records and staff interview, it was determined that the facility failed to revise a care plan for two of six residents (Resident R1, R2) to accurately reflect the current status of the resident. Findings include: Review of clinical record indicated Resident R2 was admitted [DATE], with diagnoses which included adult failure to thrive, Parkinson's disease without dyskinesia and neurocognitive disorder. A review of Resident R2's Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 11/4/24, indicated diagnoses remained current. Review of Resident R2's physician orders dated 12/5/24 indicated Safety Devices:Wanderguard on at all times: Check placement & skin integrity each shift. Change every 84 days was discontinued on 11/4/24. Review of Resident R2's Resident Care Plan Summary Report (report nurse aides used to know what kind of care to provide) dated 8/22/24, indicated elopement risk. Care Plan interventions included wandering device Device # A3423-3494. Review of clinical…

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 facility policy review, clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exited to an unsupervised and unauthorized location without staff's knowledge) for one of six resident (Resident R1). Findings include: The facility Resident Elopement policy dated 6/3/24, indicated the facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. Review of clinical record indicated Resident R1 was admitted [DATE], with diagnoses which included encephalopathy, cognitive communication mood disorder and dysphagia. A review of Resident R1's Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 11/21/24, indicated diagnoses remained current. Review of Resident R1 nurse progress notes dated 12/18/24 at approximately 1:28 p.m., Nursing home administrator (NHA) notified 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 review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five of seven residents sampled with facility-initiated transfers (Residents R41, R49, R68, R116, and Closed Resident Record CR134). Findings include: Review of facility policy Medical Emergency dated 6/3/24, indicated if transfer is required complete transfer form and send appropriate documentation with the resident. Review of the clinical record indicated Resident R41 was admitted to the facility on [DATE]. Review of Resident R41's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/18/24, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression (a constant feeling of sadness and loss of interests). Review of the clinical record indicated Resident R41 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 review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for five of seven residents (Residents R41, R49, R68, R116, and Closed Resident Record CR134). Findings include: Review of the clinical record indicated Resident R41 was admitted to the facility on [DATE]. Review of Resident R41's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/18/24, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression (a constant feeling of sadness and loss of interests). Review of the clinical record indicated Resident R41 was transferred to hospital on 2/22/24 and returned to the facility on 3/1/24. Review of Resident R41's clinical record indicated the facility failed to include documented evidence that the facility provided a written…

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 facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for four of four residents (Residents R23, R38, R78, and R337). Findings include: Review of facility policy Care Plan and Interdisciplinary Care Conferences dated 6/3/24, indicated the care plan is a working tool that is reviewed and revised at specific intervals and as needed to reflect response to care and changing needs and goals. The purpose of the care plan is to structure and guide therapeutic interventions to meet resident's needs and achieve expected outcomes. Review of the clinical record indicated Resident R23 was admitted to the facility on [DATE]. Review of Resident R23's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/14/24, indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), repeated falls,…

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 facility policy, clinical record review, and staff interview, it was determined that the facility failed to monitor resident wounds and complete weekly skin assessments for four of four residents (Residents R52, R66, R88, and R96), failed to notify a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as per order for one of two residents (Resident R49), and failed to follow physician orders to monitor daily weights for one of three residents (Resident R116). Findings include: Review of the facility Skin Integrity and Wound Management policy dated 6/2/24, indicated the implementation of an individual resident's skin integrity and wound management occurs within the care delivery process. Staff continually observes and monitor residents for changes and implements revisions to the plan of care as needed. It was indicated staff must perform skin inspections on admission and weekly by a licensed nurse and it must be documented in the resident's electronic record. Wound…

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 facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for four of four residents (Resident R50, R67, R68, and R128). Findings include: Review of facility job description Social Worker, indicated that the Social Worker will carry out social evaluations and plan interventions based on evaluation findings, and counsel residents/ family/caregivers as needed in relationship to stress and other identified coping difficulties. Ensure compliance with all Federal, State, and local regulations. Review of the clinical record indicated Resident R50 was admitted to the facility on [DATE]. Review of Resident R50's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/17/24, indicated diagnoses of PTSD (post-traumatic stress disorder- a mental health condition that is caused by an extremely stressful 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 review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in two out of three medication carts (Pleasant Valley Back Medication Cart and Buttercup Back Hallway Medication Cart) and one of three medication rooms (Angel Wing Medication Room). Findings include: Review of facility policy Medication Storage in the Facility dated [DATE], indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal. Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication Is in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility admission documents and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the Notice of Medicare Non-Coverage (NOMNC) form and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands for one of three residents (Closed Record (CR) Resident R1). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019 indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of CR Resident R1's admission record indicated the resident was admitted to the facility on [DATE]. Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of four three units (Pleasant Valley Back Medication Cart). Findings include: Review of facility policy HIPAA/HITECH Administrative Policy dated 6/3/24, indicated the facility is to protect residents' privacy rights and their individually identifiable health information as required by the Health Insurance Portability and Accountability Act (HIPAA), Standards for Privacy of Individually Identifiable Health Information, 45 CRF Parts 160 and 164, the Health Information Technology for Economic and Clinical Health Act (HITECH) and all Federal regulations and interpretive guidelines promulgated thereunder. During an observation on 8/20/24, at 9:09: a.m. the Pleasant Valley Back Medication Cart outside of room [ROOM NUMBER] was left unattended with the computer screen open with identifiable information any passerby could see 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 review of facility policies and clinical records, and staff interviews it was determined that the facility failed to assess the functional status of one of two resident (Resident R99) to determine if the use of a seatbelt is a restraint, and failed to develop a care plan for a seatbelt for one of two residents (Resident R2) Findings include: The facility Physical Restraint policy last reviewed 6/3/24, indicated that physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restrict freedom of movement or normal access to one's body. The resident must be physically and cognitively able to self-release devices such as Velcro lap trays or tables, seat belts with Velcro, or easy snap seat belts. If a resident cannot mentally and physically self-release, then the device is considered a restraint. The elimination potential of a physical restraint will be re-assessed 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 a review of the clinical record and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for one of six residents (Resident R90). Findings include: Review of the facility Activity Protocol policy dated 6/3/24, indicated the activity department will provide resident centered activities in both group and independent leisure setting that promote each resident's physical, mental, and psychosocial well-being. It was indicated residents will be offered activities daily. Review of Resident R90's clinical record indicated an admission date of 1/13/20, with diagnoses of cerebrovascular accident (also known as a stroke, occurs when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel), aphasia (disorder that affects how you communicate), and dementia (a group of symptoms affecting memory, thinking and social abilities). Review of Resident R90's care plan last revised 4/27/24,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation, clinical record review, and staff interviews, it was determined that the facility failed to provide colostomy (a surgical process that diverts bowel through an artificial opening in the abdomen wall) care and services consistent with professional standards of practice for one of two residents reviewed (Resident R76). Findings include: Review of facility policy Ostomy Care dated 6/3/24, indicated ostomy care will be provided for residents who have a colostomy. Ostomy appliances are changed as needed. The purpose is to maintain integrity of peristomal skin (skin around the opening), manage odor, and promote resident ' s self-esteem. Access the color of the stoma (the opening and skin integrity. Review of the admission record indicated Resident R76 was admitted to the facility on [DATE]. Review of Resident R76's MDS (MDS - a periodic assessment of care needs) dated 5/28/24, indicated the diagnoses of high blood pressure, depression, and heart failure (a condition 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for one of four residents reviewed (Resident R81). Findings include: Review of the facility policy Oxygen Therapy via Nasal Cannula dated 6/3/24, indicated oxygen therapy via nasal cannula will be administered as ordered by a physician and will include correct flow rate, concentration, mode of delivery, and frequency. Oxygen will be set up, delivered, and monitored by a licensed nurse or a respiratory therapist, as appropriate. Nasal cannula labeled with resident's name and date of initial set up. Replace cannula every seven days, date, and store in plastic bag when not in use. Review of admission record indicated Resident R81 admitted to the facility on [DATE]. Review of Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/6/24, indicated the diagnoses of high blood pressure, depression, and cancer (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records and facility policy review, and staff interview, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services to correct the problem for one of six residents (Resident R84). Findings include: Review of the facility Behavior Standard policy last reviewed 6/3/24, indicated residents with dementia receive person-centered care and their individual needs and preferences are recognized. Review of the facility policy Comprehensive Care Plan-CU8.5 dated 6/3/24, indicated a resident's care plan reflects the individual's goals and choices, and identifies individual specific interventions. Review of the facility's Care Plan and Interdisciplinary Care Conferences- NU 6.1 dated 6/3/24, indicated an individualized, interdisciplinary care plan is initiated within 24 hours for each resident as part of the care delivery process. Review of Resident R7's clinical record indicated the 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 a review of clinical records and staff interview, it was determined that the facility failed to ensure a resident with dementia receives the appropriate treatment and services to attain or maintain his highest practicable physical, mental, and psychosocial well-being for one of four residents reviewed (Resident R7). Findings include: Review of the facility Behavior Standard policy last reviewed 6/3/24, indicated residents with dementia receive person-centered care and their individual needs and preferences are recognized. Review of Resident R7's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses that included high blood pressure, depression, dementia (loss of cognitive function, thinking, remembering, and reasoning). A Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated 5/22/24, indicated the diagnoses were current. Review of Resident R7's care plan dated 5/29/24, failed to include a care plan for 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 review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for one of one of three quarters (January 2024 through March 2024). Findings include: Review of facility policy Quality Assurance Performance Improvement (QAPI) Structure, Scope and Plan dated 6/3/24, indicated a QAPI Committee shall be established to administer the QAPI Plan as it pertains to that home. Members of the homes' QAPI Committee will consist of at least the following: Nursing Home Administrator, Director of Nursing, Medical Director, Personal Care Administrator, Consultant Pharmacist, Direct Care Team Member, Medical Records representative, Laundry/Housekeeping Director, Maintenance Director, Activities Director, Social Worker, Culinary Director, Human Resources Director, RNAC, at least one member of the Safety Committee, Laboratory representative, Community Member, and Representatives from any Performance…

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, observations, and staff interviews, it was determined that the facility failed to properly monitor resident's personal refrigerators to ensure that food is properly stored and maintained for three out of three residents (R22, R76, and R110). Findings include: Review of facility policy Food Brought in From Outside Sources dated 6/3/24, indicated it is the policy of the facility to provide safe and sanitary storage, handling, and consumption of food, including food and fluids brought in from outside sources. - The refrigerators will be maintained at or below 41 degrees. - Freezers will be kept at zero degrees and below. - Facility staff will monitor and document the temperature daily. - Sanitation of the refrigerator will be maintained by facility staff member. - Items brought into the facility must be labeled with the resident ' s name and date it was prepared. During an observation on 8/21/24, at 10:05 a.m. Resident R22 had a small personal refrigerator on his bedside nightstand. During an observation on 8/22/24, at 9:15 a.m. the contents inside…

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 facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that a pneumococcal immunization was offered to one of five residents (Resident R25). Findings include: Review of the facility policy Standing Orders for Administering Pneumococcal Vaccine to Adults last reviewed 6/3/24, indicated that the pneumococcal vaccination will be offered and documented in the resident's medical chart and personal immunization record card. Review of the admission Record indicated that Resident R25 was admitted to the facility on [DATE]. Review of Minimum Data Set (MDS-periodic assessment of care needs) dated 7/8/24, included diagnoses of high blood pressure, constipation, and depression. Review of Resident R25's clinical record on 8/21/24, at 9:20 a.m. indicated a consent was required for the pneumovax immunization. During an interview on 8/22/24, at 10:23 a.m. the Infection Preventionist Employee E3 confirmed that the facility failed to make certain that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to notify a physician of abnormal vital signs for one of four residents (Resident R1). Findings include: Review of the facility Physician Notification last reviewed 6/1/23, indicated upon identification of a resident who as clinical changes, change in condition, or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to physician as indicated. Review of the facility Resident Change in Condition or Status last reviewed 6/1/23, indicated when a residents exhibits a change in condition from their baseline, the licensed nurse assigned to the resident must ensure timely notification to physician. Review of the clinical record indicated that Resident R1's was admitted to the facility on [DATE], with diagnoses of high blood pressure, anxiety, and atrial fibrillation (abnormal heartbeat). Review of Resident R1's Minimum Data Set (MDS - 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record, facility policy, and staff interview, it was determined that the facility failed to develop a baseline care plan that included interventions needed to provide effective and person-centered care for one of four residents (Resident R1). Findings include: The facility policy Care Plan and Interdisciplinary Care Conferences- NU 6.1 last reviewed 6/1/23, indicated an individualized, interdisciplinary care plan must be initiated within 24 hours. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses of high blood pressure, anxiety, and colostomy status (opening (stoma) in the large intestine). Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/3/24, indicated the diagnoses were current. Review of Resident R1's baseline care plan dated 3/2/24, failed to include interventions for the resident's colostomy. During an interview on 4/10/24, at 11:12 a.m. Registered Nurse Supervisor, Employee E3…

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 clinical records, and staff interviews, it was determined that the facility failed to make certain that appropriate treatments and services were provided for a foley catheter and ostomy as required for one of five residents (Resident R1). Findings include: Review of the facility Ostomy Care- NU 10.17 policy dated 6/1/23, indicated ostomy care will be provided for residents who have a colostomy. Ostomy appliances are changed and pouches are emptied as needed. It was indicated to change the ostomy appliance, appropriate size and type, and stoma measuring guide is needed. Review of the facility Catheter: Use of NU- 10.11 dated 6/1/23, indicated treatment must be initiated according to the physician's order. Review of the clinical record indicated that Resident R1's was admitted to the facility on [DATE], with diagnoses of high blood pressure, anxiety, and atrial fibrillation (abnormal heartbeat). A review of Resident R1's Minimum Data Set Assessment (MDS, periodic assessment of resident care…

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 facility documents, clinical record review and staff interview, it was determined that the facility failed to make certain that a resident with limited bed mobility received services to maintain safety and maintain or improve bed mobility for one of three residents (Resident R1). Findings include: Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual effective October 2019, indicated that bed mobility is defined as how resident moves to and from a lying position, turns side or side, and positions body while in bed or alternate sleep furniture. The RAI further indicated that How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting. Review of American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down.…

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 facility documents, clinical records, and staff interviews, it was determined that the facility failed to provide adequate supervision for bed mobility for one of three residents, that resulted in a resident falling out of bed (Resident 1). Findings include: Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual effective October 2019, indicated that bed mobility is defined as how resident moves to and from a lying position, turns side or side, and positions body while in bed or alternate sleep furniture. The RAI further indicated that How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting. Review of American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. Review of Resident R1's admission…

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 clinical records and staff interviews it was determined that the facility failed to identify a case of Legionella, evaluate and analyze hazards and risks, and implement interventions to reduce hazards and risks in a timely manner for one of three residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record indicated he was admitted [DATE], and readmitted on [DATE], with diagnoses that included dementia (a decline in cognitive abilities that impacts a person's ability to perform everyday activities), Legionnaires' disease (a lung infection caused by bacteria Legionella), and high blood pressure. Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 9/30/23, indicated that the diagnoses were current upon review. Review of Resident R1's Nurse Hand-Off Report dated 9/26/23, indicated the resident was admitted to the hospital with a diagnosis of Legionella pneumonia. Review of Resident R1's Discharge…

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 facility policy, observation, and staff interview, it was determine the facility failed to provide privacy and confidentiality of resident healthcare information on three of three residents (Resident R7, R57, R70, and R118). Findings include: Review of facility policy titled HIPPA/HITECH Administrative Policy dated 4/1/15, last reviewed 6/1/23, states the purpose is to protect resident's privacy rights and their individually identifiable health information as required by the Health Insurance Portability and Accountability Act (HIPPA), Standards or Privacy of Individually Identifiable Health Information, 45 CFR Parts 160 and 164, the Health Information Technology for Economic and Clinical Health Act (HITECH), and all federal regulations and interpretive guidelines. During an observation on 9/11/23, at 10:29 a.m., Resident R57's [NAME] (document with resident healthcare information) was observed taped inside the resident's closet in their room. The resident name, date of birth , age, and care information…

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 facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans to meet care needs for five of twenty-nine residents (Residents R31, R49, R63, R91, and R100). Findings include: Review of facility policy Care Plan and Interdisciplinary Care Conferences dated 6/1/23, indicated the care plan is a working tool that is reviewed and revised at specific intervals and as needed to reflect response to care and changing needs and goals. The purpose of the care plan is to structure and guide therapeutic interventions to meet resident's needs and achieve expected outcomes. Review of the clinical record indicated that Resident R31 was admitted to the facility on [DATE]. Review of Resident R31's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/23/23, indicated diagnoses of Chronic Obstructive Pulmonary Disease (COPD - a group of progressive lung disorders characterized by increasing breathlessness),…

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 facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for three of twenty-nine residents (Residents R21, R108, and R54). Findings include: Review of facility policy Care Plan and Interdisciplinary Care Conferences dated 6/1/23, indicated the care plan is a working tool that is reviewed and revised at specific intervals and as needed to reflect response to care and changing needs and goals. The purpose of the care plan is to structure and guide therapeutic interventions to meet resident's needs and achieve expected outcomes. A review of the clinical record indicated Resident R54 was admitted to the facility on [DATE] with diagnoses that included muscle weakness and neoplasm (abnormal growth of tissues that may or may not be cancerous) of rectum. A review of Resident R54's MDS (MDS-- minimum data assessment: a periodic assessment of 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 review of facility policy, personnel files and staff interview it was determined that the facility failed to complete annual performance evaluations for four out of five personnel records (Nurse Aide (NA) Employee E15, Nurse Aide (NA) Employee E16, Nurse Aide (NA) Employee E17, and Nurse Aide (NA) Employee E18). Findings include: The Facility assessment dated 7/2023 indicated that staff general competencies are completed upon hire and annually. Review of Nurse Aide (NA) Employee E15's personnel record indicated she was hired on 3/6/08. Nurse Aide (NA) Employee E15's job description was signed on 2/8/08. Nurse Aide (NA) Employee E15's personnel record did not include an annual performance evaluation. Review of Nurse Aide (NA) Employee E16's personnel record indicated she was hired on 8/21/08. Nurse Aide (NA) Employee E16's job description was signed on 8/7/08. Nurse Aide (NA) Employee E16's personnel record did not include an annual performance evaluation. Review of Nurse Aide (NA) Employee E17's personnel record indicated she was re-hired on 4/18/18. Nurse Aide (NA)…

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, observation, and staff interviews, it was determined that the facility failed to develop and implement infection prevention and control policies for COVID-19 that were current and based on national standards and complete COVID-19 testing as recommended by national standards for two of two residents (Residents R72 and Resident R113). Findings include: Review of the Center for Disease Control and Preventions (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 5/8/23, stated the recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency. It stated the facility must establish a process to identify and manage individuals with suspected or confirmed COVID-19 infection, implement source control measures, perform COVID viral testing on anyone with even mild symptoms of COVID-19 or asymptomatic residents who has close contact with someone who was positive for COVID-19, and create a process to respond…

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 facility policy, resident clinical record, investigation documentations, family interview and staff interviews, it was determined that the facility failed to report an allegation of neglect within 24 hours for one out of three sampled residents (Resident R144). Findings include: The facility Resident protection from abuse, neglect, and mistreatment policy dated 6/1/23, indicated that neglect means the failure of the facility, its employees or providers, to provide goods and services to a resident that are necessary to avoid harm, pain, mental anguish or emotional distress. The Administrator will notify the Pennsylvania Department of Health via electronic reporting system within 24 hours of the incident. Review of Resident R144's admission record indicated she was admitted on [DATE], with diagnoses that included hyperlipidemia(elevated lipid levels within the blood), chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical record, investigation documentations, family interview and staff interviews, it was determined that the facility failed to conduct a thorough investigation involving an allegation of neglect for two out of three sampled residents (Resident R144 and R106). Findings include: The facility Resident protection from abuse, neglect, and mistreatment policy dated 6/1/23, indicated that neglect means the failure of the facility, its employees or providers, to provide goods and services to a resident that are necessary to avoid harm, pain, mental anguish or emotional distress. All investigations will be conducted thoroughly and will attempt to gather as much factual information as possible. Review of Resident R144's admission record indicated she was admitted on [DATE], with diagnoses that included hyperlipidemia(elevated lipid levels within the blood), chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure 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 review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that resident assessments were accurate for two of five residents (Residents R63 and R91). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2019, indicated that Section O: Special Treatments, Procedures, and Programs, Question O0100 should have all listed treatments, procedures, and programs performed during the last 14 days checked. The RAI User's Manual, dated October 2019, indicated that Section J1800 was to be coded No (0) or Yes (1) for any falls since admission. The RAI User's Manual, dated October 2019, indicated that Section O0100C (Oxygen Therapy) was to be coded yes if performed while a resident of the facility within the last 14 days. Review of the clinical record indicated that 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 staff interview, record review, and state scope of practice, it was determined that the facility failed to follow professional standards of practice for to one of four residents reviewed (Resident R141). Findings include: Review of the facility's Physician Orders-NU 2.18 policy last reviewed 6/1/23, indicated physician orders are followed in accordance with good nursing principles and practices and are transcribed out by persons legally authorized to do so. It was indicated all physician orders must be written by the resident's physician, covering physician, or physician extender. Review of the facility's Registered Nurse job description, last reviewed 6/1/23, indicated the purpose of this position is to provide care to the residents to ensure that the highest quality of care is maintained at all times. Review of Resident R141's clinical record indicated an admission of 9/7/23, with diagnosis that included a stage three sacral pressure ulcer, muscle weakness, and dementia (a gradual decline in memory, thinking, behavior and social skills). Review of Resident R141'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to administer medications as prescribed by the physician for two of two residents (Resident R48 and R113). Findings include: A review of the clinical record indicated Resident R48 was admitted to the facility on [DATE], with diagnoses that included anemia, gastroduodenitis (an intestinal condition caused by inflammation in the duodenum lining) and type 2 diabetes mellitus (metabolic disorder impacting organ function related to glucose levels in the human body). A review of Resident R48's quarterly MDS assessment(minimum data assessment: a periodic assessment of resident care needs) dated 8/8/23, indicated the diagnosis remained current. A review of Resident R48's physician orders dated 9/7/23, indicated HumaLOG Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 1 - 69 = 0 follow hypoglycemia protocol; 70 - 149 = 0; 150 - 199 = 1; 200 - 249 = 2; 250 - 299 = 3; 300 - 349 = 4; 350 - 399 = 5; 400 -…

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 facility policy and records, and a staff interview, it was determined that the facility failed to provide pressure ulcer treatment consistent with professional standards of practice by ensuring weekly wound assessments and treatment were completed as ordered for two of five residents reviewed (Resident R79 and R141). Findings: A review of the Skin Integrity and Wound Management policy dated 6/1/23, indicated it is the facility's policy to continually observe and monitor residents for changes and implement revisions to the plan of care as needed. A review of the clinical record indicated that Resident R79 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses that included paraplegia (paralysis of all or part of the trunk, legs, and pelvic organs) and a sacral pressure ulcer. A review of Resident R79's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 6/16/23, indicated the diagnosis were current. Section M: Skin…

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 clinical records and staff interview, it was determined that the facility failed to make certain that residents who require dialysis (hemodialysis-treatment to filter wastes and water from the blood) receive services, consistent with professional standards of practice for two of three residents (Resident R48 and R18). Findings include: A review of the clinical record indicated Resident R48 was admitted to the facility on [DATE], with diagnoses that included anemia, gastroduodenitis (an intestinal condition caused by inflammation in the duodenum lining) and type 2 diabetes mellitus. A review of Resident R48's quarterly MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 8/8/23, indicated the diagnosis remained current. A review of physician orders dated 9/13/23, indicated assess Left arm AV fistula , observed for bruit and thrill (AV fistula: a connection between an artery and a vein used for dialysis. for bruit: a sound of turbulent blood 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.