Athens Nursing And Rehabilitation Center

Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on one of two nursing units (Ivy unit and Residents 8 and 39).Findings include: Observation of Resident 8's room on May 18, 2026, at 1:05 PM revealed strong urine-like odor, and a pile of linens in a soiled linen bag with some linens noted on top of the bag. Concurrent interview with the resident revealed that she is incontinent of bladder and frequently urinates on the floor, then cleans it independently and puts the soiled linens on the floor to be collected later. During resident interview, Employee 18, housekeeping, was observed entering the residents' room and stating, The floor is not as sticky today. Observation of Resident 8's room on May 19, 2026, at 11:38 AM revealed that the room continues to have a strong urine-like odor, and the floor remained sticky underfoot. Observation of Resident 39's bathroom on May 19, 2026, at 10:07 AM revealed that the floor was sticky underfoot. 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 clinical record review and staff interview it was determined that the facility failed to ensure resident representative contact information was communicated to the receiving health care institution for one of four residents reviewed for hospitalization concerns (Resident 2).Findings include: Clinical record review for Resident 2 revealed nursing documentation dated April 22, 2026, at 6:40 PM that Resident 2 wanted to go to the emergency room due to pain in his back. Emergency services (911) were at the facility and transported Resident 2 via a stretcher. The writer indicated that Resident 2's sister was made aware of the transfer. Review of Resident 2's clinical record profile information revealed his sister was listed as his representative. An, eINTERACT Transfer Form (document generated by the facility's electronic medical record system to ensure appropriate information is communicated to a receiving health care institution or provider), dated April 22, 2026, completed for Resident 2's discharge to the hospital, revealed that Resident 2 was listed as his own resident…

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

Based on clinical record review and staff interview it was determined that the facility failed to ensure that an assessment accurately reflected a resident's status for one of 18 residents reviewed (Resident 2).Findings include: Clinical record review for Resident 2 revealed nursing documentation dated April 22, 2026, at 3:08 PM that Resident 2 was on the floor. Resident 2 complained of mid back pain. Nursing documentation dated April 22, 2026, at 6:40 PM revealed that Resident 2 insisted on going to the emergency room due to back pain and 911 (emergency personnel) transported Resident 2 to the emergency room. Nursing documentation dated April 23, 2026, at 10:57 AM revealed that the writer called the hospital and obtained information that Resident 2 was admitted for vertebral (spinal) fractures for which he was going to have surgery. A Discharge MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated April 22, 2026, assessed that Resident 2 had a fall with an injury that was not coded as a major injury. The facility staff…

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

Based on clinical record review, observation, and staff interview it was determined that the facility failed to revise a resident's plan of care for one of 18 residents reviewed (Resident 30).Findings include: Clinical record review for Resident 30 revealed an active physician's order dated February 6, 2026, that Resident 30 was to wear tubigrips (specially designed elastic bandages used to reduce swelling) to his bilateral lower extremities every day. Observation of Resident 30 on May 19, 2026, at 10:22 AM revealed that his lower legs and ankles presented with swelling and he was not wearing tubigrips. Review of Resident 30's plans of care developed by the facility to address his care needs revealed no intervention that included the use of tubigrips daily to his bilateral lower extremities. Review of Resident 30's MAR/TAR (Medication Administration Record/Treatment Administration Record, electronic documentation completed by licensed nursing staff for the completion of care) dated May 2026 revealed that staff initialed the application of the tubigrips in the morning. The surveyor…

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

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide a dependent resident with activities of daily living assistance for one of two residents reviewed (Resident 48).Findings include: Observation of Resident 48 on May 18, 2026, at 2:31 PM and May 19, 2026, at 12:34 PM revealed she was in bed and her hair appeared greasy. Interview with Resident 48 on May 19, 2026, at 12:34 PM revealed the resident was unable to recall when she last received a shower. Resident 48 stated she is supposed to receive a shower once a week. Clinical record review revealed the facility admitted Resident 48 on September 3, 2025. A review of Resident 22's most recent MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated March 27, 2026, indicated nursing staff assessed Resident 48 as dependent on staff for bathing. Review of Resident 48's plan of care-initiated September 3, 2025, revealed Resident 48 has an activity of daily living self-care performance deficit and is totally dependent…

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

Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions to prevent falls for two of four residents reviewed for falls (Residents 8 and 37).Findings include: Clinical record review of Resident 37 revealed a fall without injuries occurring on February 13, 2026, in the resident's shower. The Interdisciplinary team determined that adding non-slip strips (tacky/rough material that adheres to surfaces) to the resident's shower would be an appropriate intervention, and that the care plan care plan (an outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes, represented as the Focus, Goal, and Interventions) would be updated to reflect this. Observation of the resident's shower on May 20, 2026, at 9:30 AM revealed no non-slip strips were present. Interview with Employee 17, nurse aide, on May 20, 2026, at 934: AM, confirmed that the resident did not have any non-slip strips present in the shower in Resident 37's room, nor were any non-slip strips…

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 documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents who utilize a lift, wound vac, PICC line, catheter care, medication administration, and dressing changes for two of four employees reviewed for competencies (Employees 5 and 6).Findings include: A review of the facility documentation revealed that the facility had a total of 70 residents receiving medications, 12 residents that utilize lifts (transfer equipment), one resident with a wound vac (medical device used to promote healing of complex wounds by applying controlled suction to the wound area) five residents with indwelling urinary catheters (insertion of a tube into the bladder to remove urine), 11 residents with dressing changes, one resident with IV therapy (intravenous therapy, a medical procedure that delivers fluids, medications, nutrients directly into a vein), and one resident with a PICC line (peripherally inserted central catheter…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed and responded appropriately to pharmacy recommendations for two of five residents reviewed (Residents 3 and 10).Findings include: The policy entitled Consultant Pharmacist Reports, last reviewed without changes on April 1, 2026, revealed a record of the consultant pharmacist's observations and recommendation is made available in an easily retrievable form to nurses, physicians, and care planning team. Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. Recommendations are acted upon and documented by the facility staff and/or physician. If the physician does not respond to recommendations directed to him/her within 45 days, the Director of Nursing and/or the consultant pharmacist may contact the medical director. Clinical record review for Resident 3 revealed a consultant pharmacy…

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, observation, and resident, staff, and family interview, it was determined that the facility failed to provide routine dental services for two of four residents reviewed for dental concerns (Residents 22 and 3). Findings include: Interview with Resident 22's daughter on May 18, 2026, at 2:17 PM revealed that she believed Resident 22 had, bad natural teeth; I think they are beyond (repair) at this point. Resident 22's daughter stated that she was not opposed to her mother receiving services from the facility's contracted dental provider. Clinical record review for Resident 22 revealed an annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], that assessed Resident 22 as having obvious or likely cavity or broken natural teeth. The CAA (Care Assessment Area) for dental concerns triggered to prompt the facility to develop a plan of care regarding dental needs. Review of a plan of care initiated by 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 closed clinical record review and staff interview, it was determined that the facility failed to ensure an accurately documented clinical record for one of 21 residents reviewed (Resident 77).Findings include: Closed clinical record review for Resident 77 revealed that the facility discharged her on April 14, 2026. Nursing documentation dated April 14, 2026, at 10:06 PM revealed that Resident 77 was without response to verbal stimuli, without respirations. and without heart sounds. The nurse documented Resident 77's time of death as 9:30 PM. Nursing documentation dated April 14, 2026, at 11:32 PM revealed that the funeral home removed Resident 77's body from the facility. Physician discharge documentation dated April 14, 2026, at 11:54 PM noted, Care Plan: Comments: Encourage low salt diet and moderation with fluids. Otherwise fairly stable fluid status at this time. The surveyor reviewed the above concerns regarding inaccurate clinical documentation for Resident 77 during an interview with the Nursing Home Administrator and the Director of Nursing on May 20, 2026, at 8:29…

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

Based on a review of Quality Assurance and Performance Improvement (QAPI) meeting attendance and staff interview it was determined that the facility failed to ensure the committee met at least quarterly and consisted of the minimum members (Infection Preventionist).Findings include: Review of facility documentation of QAPI committee meeting attendance dated August 26, 2025, to April 30, 2026, revealed that the facility failed to conduct a meeting for the first quarter of 2026 (January, February, or March). Attendance records indicated that the facility conducted a meeting on December 30, 2025, and again on April 30, 2026. Review of the attendance records dated April 30, 2026, revealed that the infection preventionist did not attend the meeting. Interview with the Nursing Home Administrator on May 21, 2026, at 11:03 AM confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3)(e)(3) Management

Based on staff interview, it was determined that the facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. Findings include: During an interview on July 1, 2025, at 10:10 AM, Employee 2, registered dietitian indicated she was only employed at the facility three days a week (not full-time). Concurrently, Employee 1, dietary manager, indicated she was not a certified dietary manager, certified food service manager, did not have a national certification for food service management and safety, and did not hold a degree in food service management. In a follow up interview on July 1, 2025, at 12:00 PM the Nursing Home Administrator confirmed the facility did not employe a full-time qualified dietitian or qualified director of food and nutrition services. Cross Refer F812 28 Pa. Code 201.18(b)(1)(3) Management

Based on observation and staff interview, it was determined that the facility failed to maintain food service equipment in accordance with professional standards for food service safety and store food in a sanitary manner in the facility's main kitchen and on two of two nursing units (Sage and Ivy). Findings include: An observation in the facility's main kitchen on July 1, 2025, at 10:10 AM with Employee 1, dietary manager, revealed the following: The interior of the water wells of the steam table were observed on (hot), with water in the compartments (wells that hold water produce the steam to keep pans of food placed above the water hot). Employee 1 indicated breakfast had been served and the breakfast pans had already been removed from the steam table. The interior base of the steam table compartments was coated in a buildup of brown film. A significant amount of food debris was also observed floating in the water of the compartments including vegetables, potatoes, and other food debris that was not served at breakfast. A two-door cooler was observed with three plastic bins on…

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

Based on observation and staff interview, it was determined that the facility failed to ensure resident's privacy during a medication pass while utilizing staff personal electronic devices for two of two nursing units (Ivy and Sage Nursing Units) for one of 19 sampled residents (Residents 20). Findings include: Review of facility documentation entitled, Athens Nursing and Rehabilitation Center Orientation, revealed that all staff attend and review this orientation upon hire. The orientation documentation revealed that staff received education on the HIPPA (Health insurance Portability and Accountability) Act of 1996, confidentiality, privacy, and resident rights. HIPPA protects protective sensitive patient information from being disclosed without their consent or knowledge. A HIPPA violation is punishable by law and could be subject to fines or jail time. Residents have the right to have their personal information kept private. Interview with the Nursing Home Administrator (NHA) on July 2, 2025, at 2:200 PM confirmed that staff complete orientation and that this information 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.

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered interventions and treatments for one of 19 residents (Resident 67). Findings include: Clinical record review for Resident 67 revealed physician orders for the following: Ordered on May 29, 2025, and discontinued on June 22, 2025, for only registered nursing (RN) staff to drain the Aspira catheter (a chest tube/catheter inserted into the lung area/cavity to drain excessive fluids) every other day on day shift. RN staff were not to exceed 1000 ml (milliliters) of fluid each time. Staff were to document the output, color, and character of drainage in a progress note, Ordered on May 29, 2025, and discontinued on June 22, 2025, for only RN staff to change the Aspira chest tube/catheter drain dressing every other day on day shift. Ordered on June 5, 2025, and discontinued on June 22, 2025, for only RN staff to change the Aspira chest tube/catheter drain connecting valve weekly on day shift. Clinical record review for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to establish clear advance directives for one of 24 residents reviewed (Resident 28). Findings include: Clinical record review for Resident 28 revealed a physician's order dated [DATE], indicating the resident was to be a DNR (do not resuscitate, do not perform CPR (cardiopulmonary resuscitation) if the person has no pulse and is not breathing). Record review for Resident 28 also revealed a POLST (Pennsylvania orders for lift sustaining treatment) dated [DATE], that indicated Resident 28 desired to be a full code (attempt CPR when the person has no pulse and is not breathing). The POLST was signed by the resident. There was no documented evidence identified or provided by facility staff to indicate Resident 28 completed an updated POLST after [DATE], or had discussions with facility staff or the physician indicating a change in wishes for life sustaining treatment was desired. The above information regarding 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 observation and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on one of two nursing units (Sage; Residents 27 and 66). Findings include: Observation on July 1, 2025, at 11:42 AM revealed Resident 27's room had damage to the wall next to the bathroom door. There was 10 to 12 inches of exposed drywall paper. A hand sanitizer dispenser was installed, covering a portion of the damaged area. Observation on July 1, 2025, at 11:55 AM of Resident 66 room revealed a 2-inch area of exposed drywall paper on the wall next to the bathroom door. A hand sanitizer dispenser was installed, covering a portion of the damaged area. Observation of the Sage Nursing unit hallway on July 1, 2025, at 12:05 PM revealed a painted handrail with the paint rubbed off, exposing the underlying metal. This damage was most severe at the intersection of two hallways, next to the nursing station. Dried brown liquid splatter was observed on the lower portion of the wall behind two medication carts located across from the nursing station. A…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement interventions related to fall prevention for two of six residents reviewed (Residents 7 and 46). Findings include: Clinical record review for Resident 7 revealed a diagnosis list that included the following: unsteadiness on feet, dementia (a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons), abnormalities of gait and mobility, and muscle weakness. Clinical record review for Resident 7 revealed a quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated May 6, 2025, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 4, which indicated severe cognitive impairment. Current physician orders for Resident 7 dated April 28, 2025, at 10:30 PM indicated the resident was to have a bed/chair alarm and check…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate Enhanced Barrier Precautions (EBP) for one of 24 residents reviewed (Resident 276). Findings include: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, device care, etc. During an observation and interview with Resident 276 on July 1, 2025, at 3:07 PM an enhanced barrier sign was observed outside Resident 276's door. Resident 276 indicated that he had a urinary foley catheter (a…

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

Based on a review of facility documentation, employee personnel record information, and staff interview, it was determined that the facility failed to ensure that nurse aide staff possessed the specific competencies, and skill sets related to transfer techniques for three of three employees reviewed (Employees 1, 2, and 3). Findings include: The Centers for Medicare and Medicaid Services (CMS) QSO-24-13-NH memo dated June 18, 2024, noted that requirements specify that the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions), and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. The assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess to deliver the necessary care required by the residents being served. The Facility…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure an environment free from potential accident hazards for two of three residents reviewed (Residents 2 and CR1). Findings include: Closed clinical record review for Resident CR1 revealed nursing documentation dated April 9, 2025, at 7:38 PM that the licensed practical nurse (LPN) noted an .obvious smell of marijuana attempting to be covered by (scented brand) air spray. Per the documentation, the LPN notified the registered nurse supervisor of the situation. Resident CR1's closed clinical record contained no evidence that the registered nurse supervisor investigated the allegation of potentially illegal drugs in the facility. Nursing documentation by a different LPN on April 12, 2025, at 2:30 PM revealed that Resident CR1's room smelled like marijuana. When the LPN asked Resident CR1 if she was smoking marijuana in her room, Resident CR1 reportedly .just smiled and stated well I need some kind of pain relief. Per the documentation, the LPN notified the registered nurse supervisor…

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 select facility policies and procedures, Centers for Disease Control (CDC) standards, clinical record review, review of personnel payroll records, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of COVID-19 infection related to work exclusions for two of two employees reviewed (Employees 1 and 2), contact tracing for four of four residents reviewed (Sage nursing unit: Residents CR1, 1, 2, and 3), and transmission based precautions for two of four residents reviewed (Residents 1 and 3). Findings include: The facility policy entitled, Coronavirus Disease (COVID-19) Work Restrictions and Return to Work Criteria for Staff, last reviewed March 1, 2025, revealed that staff with mild to moderate illness who are not moderately to severely immunocompromised may return to work after the following criteria are met: At least seven days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if 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 closed clinical record review and staff interview it was determined that the facility failed to provide a discharge summary with the necessary components for two of two closed records reviewed (Residents CR1 and CR2). Findings include: Closed clinical record review for Resident CR1 revealed nursing documentation dated July 10, 2024, at 5:33 PM that Resident CR1 was discharged to home with home health services. An electronic Discharge summary dated [DATE], revealed no evidence that Resident CR1 or her responsible party received the document. The document did not include a reconciliation of all medications with Resident CR1. Closed clinical record review for Resident CR2 revealed nursing documentation dated July 26, 2024, at 3:14 PM that arrangements were made for home health and infusion (intravenous medication) therapy to assist with wound treatment and continuous antibiotic infusion in her home. Resident CR2's son assisted Resident CR2 from the facility via the family car. The documentation indicated…

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 select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection for two of two residents reviewed for COVID-19 transmission based precaution concerns (Residents 1 and 3). Findings include: The facility policy entitled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, last reviewed without changes on August 1, 2023, revealed that the facility follows infection prevention and control (IPC) practices recommended by the Centers for Disease Control (CDC) and Prevention to prevent the transmission of COVID-19 within the facility. The infection prevention and control measures that are implemented to address the SARS-CoV-2 are incorporated into the facility infection prevention and control plan. These measures include: Ensuring everyone is aware of recommended IPC practices in the facility, including the use of visual alerts with dates to reflect that recommendations are current and implementing…

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

Based on observation and staff interview, it was determined that the facility failed to store food items and maintain equipment in a safe and sanitary manner in the facility's main kitchen. Findings included: Initial tour of the facility's main kitchen on June 11, 2024, between 10:25 AM and 11:07 AM revealed the following: The clear lights on the ceiling had multiple dead insects and debris accumulated in the protective covers. There were opened bread products on a plastic rack near the kitchen entrance with no open dates that included the following: a partially used bag of hamburger buns, an open bag of hot dog buns, and a partially used loaf of bread. A wire storage rack in front of the sink had a build-up of debris on the bottom protective cover/shelf. There was a significant build-up of debris at the perimeter of the kitchen where the floor meets the wall. There was an extensive build-up of dust inside of the steamer exhaust area. A second wire storage rack had debris accumulating on the bottom cover/shelf. A clear plastic container holding various green and red lids 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 clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility bed hold policy at the time of transfer for six of seven residents reviewed for hospitalization concerns (Residents 3, 37, 59, 19, 34, and 60). Findings include: Clinical record review for Resident 3 revealed nursing documentation dated April 3, 2024, at 1:34 PM that Resident 3 was admitted to the hospital from her appointment with the wound care consultant provider. Resident 3 had a surgical procedure for a below the knee amputation. Nursing documentation dated May 11, 2024, at 1:36 AM revealed that Resident 3 had emesis resembling coffee grounds (indicative of gastrointestinal bleeding), had abdominal discomfort, and staff called emergency transport. An emergency room history and physical dated May 10, 2024, indicated that Resident 3 was admitted from the emergency room. A review of a Bed Hold/Transfer/Therapeutic Leave Notification form (form the facility utilized to communicate to a 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 observation, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to promote healing and prevent infections regarding pressure ulcers for two of seven residents reviewed (Residents 58 and 59). Findings include: Review of Resident 58's clinical record revealed a physician's order dated March 16, 2024, indicating that nursing staff were to perform wound care to Resident 58's coccyx (sacral area) wound twice a day by packing the wound with half strength betadine-soaked gauze and a dry dressing. Review of Resident 58's Treatment Administration Record (TAR, a form utilized to document the completion of treatments) dated March 2024, revealed that nursing staff did not complete the treatments on the evening of March 16, 2024, and March 18, 2024, the morning of March 19, 2024, and March 21, 2024. There was no additional documented evidence to indicate that nursing staff completed Resident 58's wound care as ordered by her physician. Review of Resident 58's weekly wound assessments revealed that the 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.

Based on clinical record review and staff interview, it was determined that the facility failed to provide physician ordered interventions for two of six residents reviewed for nutritional risk (Residents 25 and 59). Findings include: Review of Resident 25's plan of care dated August 6, 2020, and last revised on December 25, 2023, indicated that the facility determined he was a nutritional risk. The facility indicated that an intervention of a nutritional supplement would benefit him and maintain his skin integrity. A physician's order dated July 25, 2023, indicated that nursing staff were to provide 8 oz (ounces) of Boost (a nutritional supplement) twice a day. Review of Resident 25's Medication Administration Record (MAR, a form utilized to document the administration of select physician orders) dated April 2024, indicated that nursing staff did not give him the Boost five times, documenting that it was unavailable or on order. Review of Resident 25's MAR dated May 2024, indicated that nursing staff did not give him the Boost 26 times documenting that it was unavailable, none in…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for four of five residents reviewed (Residents 10, 22, 25, and 46). Findings include: Review of Resident 10's clinical record revealed that the pharmacist made recommendations on the following dates: February 25, 2024, and November 20, 2023. There was no documented evidence in Resident 10's clinical record to indicate what the recommendations were and if the recommendations were acted upon. Interview with the Director of Nursing (DON) on June 14, 2024, at 12:00 PM confirmed the recommendations could not be located for Resident 10. Review of Resident 46's clinical record revealed that the pharmacist made recommendations on the following dates: March 28, 2024, February 25, 2024, January 28, 2024, November 20, 2023, and September 22, 2023. There was no documented evidence in Resident 46's clinical record to indicate what the recommendations were or if the recommendations were acted upon. Interview with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate clinical documentation for two of 13 residents reviewed (Residents 20 and 50). Findings include: Clinical record review for Resident 20 revealed that the resident was discharged from hospice services on March 17, 2023. Clinical documentation for Resident 20 dated May 16, 2024, at 2:21 PM revealed a physician's progress note that indicated under the notes section titled Care Plan to Continue Hospice care. Under the section titled Counseling and/or Coordination of Care of the same note it indicated to Continue skilled level of care. Clinical documentation for Resident 20 dated May 9, 2024, at 2:20 PM revealed a physician's progress note that indicated under the notes section titled Care Plan to Continue Hospice care. Under the section titled Counseling and/or Coordination of Care of the same note it indicated to Continue skilled level of nursing. Clinical documentation for Resident 20 dated April 4,…

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

Based on review of the facility's arbitration agreements and staff interview, it was determined that the facility's arbitration agreements failed to ensure a neutral and fair arbitration process by ensuring the selection of a neutral arbitrator for six of six residents reviewed with a signed arbitration agreement (Residents 34, 47, 16, 62, 49, and 26). Findings include: Review of a Mandatory Binding Arbitration Agreement (an agreement that the resident and the facility will resolve legal disputes through binding arbitration, waiving their right to a trial) signed by Resident 34 on August 22, 2022, revealed that the document stipulated that, All Arbitrations shall be administered by (name of arbitrator services company which the facility utilized). The document also stipulated that if, .(name of arbitrator services company which the facility utilized), is unable or unwilling to handle the Arbitration, the parties will work in good faith to agree on an alternative neutral arbitration service, and if the parties cannot reach an agreement within thirty (30) days, the Facility will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier transmission-based precautions for four of 13 residents reviewed (Residents 25, 49, 59, and 60). Findings include: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Interview with Employee 5, nurse aide, on June 12, 2024, at 11:18…

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 and a review of the facility's infection control program, it was determined that the facility failed to have a designated Infection Preventionist with the necessary qualifications responsible for the facility's infection prevention and control program. Findings include: Interview with the Nursing Home Administrator on June 11, 2024, at 10:02 AM revealed that the facility's previous Director of Nursing from April 1, 2024, to June 2, 2024, fulfilled the position of infection preventionist until her discontinuation of employment on June 2, 2024. The interview indicated that a current licensed practical nurse employee assumed the infection preventionist position. Interview with the Nursing Home Administrator on June 13, 2024, at 10:04 AM confirmed that no staff currently employed by the facility has completed any specialized training in infection prevention and control. The interview also confirmed that the facility could not provide any evidence of infection control committee meetings (that included the required members) since the facility's last standard…

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 select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to offer the COVID-19 vaccine as indicated by the Centers for Disease Control (CDC) for four of five residents reviewed for immunization concerns (Residents 2, 35, 36, and 60). Findings include: The facility policy entitled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, last reviewed without changes on August 1, 2023, revealed that the infection prevention and control measures that are implemented to address the SARS-Co V-2 are incorporated into the facility infection prevention and control plan. These measures include encouraging staff, residents, and visitors, to remain up to date with all COVID-19 vaccine doses. The policy provided by the facility did not include education provided to residents regarding benefits and potential risks associated with the COVID-19 vaccine, or the documentation maintained regarding education provided,…

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

Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and comfortable environment on one of two nursing units (Ivy Nursing Unit) and a facility dining room. Findings include: Observation of the facility's dining room located adjacent to the main kitchen on June 12, 2024, at 11:41 AM and June 13, 2024, at 10:40 AM revealed the following: various stains on the floor, the overhead lights had various debris in the protective covers, there were two stained ceiling tiles and one tile had a large crack in it near the middle of the room above where the residents were sitting for lunch service, debris and dust on the windowsills, and multiple dried splash stains on the glass of the windows. Observation of the shower room on June 12, 2024, at 12:26 PM revealed the following: a scratched and marred commode seat, dried and brown colored stains on the commode seat, the area behind the toilet paper roll had chipped paint, dead insects in the protective covering over the ceiling light…

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

Based on clinical record review and staff interview, it was determined that the facility failed to complete a restorative nursing program for one of three residents reviewed for activities of daily living concerns (Resident 18). Findings include: Clinical record review for Resident 18 revealed a diagnoses list that included the following: osteoarthritis (a degenerative joint disease) of the knee, abnormalities of gait and mobility, and muscle weakness. Review of the current care plan for Resident 18 revealed the resident requires assistance with walking and transferring. An intervention included one-assist with a rolling walker for mobility. Further review of the current care plan for Resident 18 revealed a restorative nursing program that noted a goal that the resident will ambulate up to 70 feet with a rolling walker, one-assist daily, and a wheelchair to follow for safety. The target date was noted as June 24, 2024. Interventions included the following: allow rest breaks as needed, encourage the resident to ambulate at her own pace, and the resident will ambulate up to 70 feet…

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, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care related to intravenous access and an implanted pacemaker for one of 13 residents reviewed (Resident 22). Findings include: The surveyor requested the facility's policy or procedure regarding care and services for the use of a PICC (PICC, long, thin, tube that is inserted through a vein in the arm and passed through to a larger vein near the heart. The line requires careful care and monitoring for complications including bleeding, infection, and blood clots) line during an interview with the Nursing Home Administrator, Director of Nursing, and Employee 6 (clinical consultant) on June 12, 2024, at 2:15 PM, and June 13, 2024, at 2:00 PM. The facility did not provide a policy pertaining to the use of a PICC line during the onsite survey. Information regarding PICC line care available from the Mayo clinic…

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide the coordination of dialysis services and administration of physician ordered medications for one of one resident reviewed (Resident 28). Findings include: Review of Resident 28's clinical record revealed that she received kidney dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) on Tuesdays, Thursdays, and Saturdays at an outside provider. Resident 28 leaves the facility to go to dialysis prior to breakfast being served around 6:45 AM. Review of Resident 28's current physician orders revealed that nursing staff are to administer the following medications in the morning: Miralax (stool softener) 17 grams, one scoop at 8:00 AM Protonix (treats acid reflux) 40 mg (milligrams) at 8:00 AM Eliquis (a blood thinner) 2.5 mg at 8:00 AM Simethicone (relives symptoms of extra gas) 125 mg at 7:00 AM Review of Resident 28's Medication Administration Record (MAR, a form utilized to document the administration of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to properly assess and obtain informed consent or provide the resident and/or responsible party with the risks and benefits for the use of side rails for two of 11 residents reviewed (Residents 10 and 34). Findings include: The policy entitled Use of Bed Rails, last reviewed without changes on August 1, 2023, revealed the purpose of the guidelines is to ensure the safe use of bed rails as resident mobility aids and to prohibit the use of bed rails as restraints unless necessary to treat a resident's medical symptoms. Further review of the policy included a section titled, General Guidelines, which noted that an assessment will be made to determine the resident's symptoms, risk of entrapment, and reason for using the bed rails. When used for mobility or transfer, an assessment will include review of the resident's bed mobility, ability to change…

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, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to wound care (Employees 1 and 2). Findings include: A review of the facility's current resident population documentation revealed that the facility had four residents who had skin concerns and/or wounds. A request for nursing staff competencies for wound care revealed the facility was unable to provide any. Interview with Employee 6, clinical consultant, on June 14, 2024, at 12:15 PM revealed that the facility does not have any competencies on Employee 1 or Employee 2 (both licensed practical nurses). The findings were reviewed with the Administrator and Director of Nursing on June 14, 2024, at 12:30 PM. 28 Pa Code 201.20(a) Staff development

Based on review of active nurse aides and staff interview, it was determined that the facility failed to complete a performance evaluation of every nurse aide at least once every 12 months for three of three nurse aides reviewed (Employees 3, 4, and 5). Findings Include: Review of the facility's list of active nurse aide staff revealed Employee 3 with a hire date in 2022; Employee 4 with hire date in 2022; and Employee 5 with a hire date in 2022. Requests to review Employees 3, 4, and 5's performance evaluations revealed no documented evidence that the facility is completing the evaluations at least once every 12 months. Interview with Employee 6, clinical consultant, on June 14, 2024, at 12:13 PM confirmed the above findings and indicated that no performance evaluations can be provided on any current nurse aide working in the facility. 28 Pa. Code 201.19 Personnel policies and procedures

Based on observation and staff interview, it was determined that the facility failed to ensure that essential equipment was in safe operating condition for the facility's main kitchen. Findings include: Observation and concurrent interview with Employee 12, Dietary Manager, of the walk-in freezer on June 11, 2024, at 11:00 AM revealed the emergency release on the interior of the freezer was broken and introduced an entrapment risk if the door would close and lock with a staff member inside of the freezer. It was unknown how long the emergency release was not functional. Employee 12 further noted that two staff members are supposed to be present when using the walk-in freezer so one staff member can stay outside to prevent the door from fully closing. Employee 12 indicated that maintenance is aware of the issue, but it has not been fixed. The Nursing Home Administrator was made aware of the issue on June 11, 2024, at 12:17 PM and again at 2:00 PM. The above was also reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on June 13, 2024, at 2:15 PM. 28 Pa.…

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

Based on review of clinical records and staff interview, it was determined that the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to ensure licensed nursing staff were knowledgeable in the necessary care and services for one of one resident reviewed with a PICC (peripherally inserted central catheter) (Resident 2) Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.145 (f) An LPN may perform only the IV therapy functions for which the LPN possesses the knowledge, skill and ability to perform in a safe manner, except as limited under § 21.145a (relating to prohibited acts), and only under supervision as required under paragraph (1). (1) An LPN may initiate and maintain IV therapy only under the direction and supervision of a licensed professional nurse or health care provider authorized to issue orders for medical therapeutic or corrective measures (such as a CRNP, physician, physician…

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

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered vital signs, medications, and interventions for two of three residents reviewed (Residents 1 and 2). Findings include: Clinical record review for Resident 1 revealed a current physician's order for staff to administer Cinnamon 500 milligrams (mg) one tablet by mouth (PO) daily for diabetes mellitus and Chromium 200 micrograms (mcg) PO daily for diabetes mellitus. Review of Resident 1's January and February 2024 MAR (medication administration record, a form to document medication administration) revealed staff were administering his Cinnamon and Chromium medications daily with the Chromium being held 14 times and the Cinnamon being held 14 times in January. Neither medication was held in February. There was no documentation in Resident 1's nursing documentation that indicated justification as to why both medications were held. Observation of a facility medication cart on February 7, 2024, at 1:25 PM with…

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