Concordia At Villa St Joseph

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to discard expired medical supplies and ensure all drugs and biologicals were stored under proper temperature controls for one of three medication rooms. (Fontbonne Medication Room). Findings include: Review of the facility policy Medication Storage in the facility dated [DATE], indicated medications and biologicals are stored safely, securely, and properly. Medications requiring refrigeration or temperatures between 36F and 46F are kept in a refrigerator with a thermometer to allow temperature monitoring. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, and disposed of. During an observation on [DATE], at 1:29 p.m. the Fontbonne Medication room contained the following expired supplies: -(3) 1ml 28g 1/2 safety syringe with needle expired [DATE] -(5) 28g 1/2 1 ml safety syringe needle…

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, observation, and staff interview, it was determined that the facility failed to thoroughly clean and disinfect a contact isolation room with the appropriate disinfectant for one of three residents (Resident R21). Findings include: Review of the facility policy Management of C. Difficile Infection Procedure dated 1/1/26, indicated the facility implements facility-wide strategies for the prevention and spread of Clostridioides difficile (C diff) infections. Use disposable equipment whenever possible. Thoroughly clean and disinfect with a sporicidal disinfectant (chemical disinfectants designed to destroy highly resistant bacterial and fungal spores). Review of the admission record indicated Resident R21 admitted to the facility on [DATE], with the diagnoses of pneumonia (lung infection), Parkinson's disease (disorder of the nervous system that results in tremors), and enterocolitis due to clostridium difficile (C-diff - contagious bacteria causing severe, watery…

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 residents were provided appropriate treatment and care by failing to assess a resident after a fall for one of four residents (Resident R1). Findings include: Review of the facility Certified Nursing Assistant job description indicated The Certified Nursing Assistant assists the licensed nursing staff by providing direct resident care related to activities of daily living. Communicates observations and findings to the Charge Nurse. Review of the facility policy Incident and Accidents last reviewed 1/2/25, indicated injuries will be assesses by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so. Review of Employee counseling reports dated 11/17/25, indicated two Nurse Aids (NA) were re-educated on residents that have a fall will require an evaluation from a Registered Nurse (RN) prior to assisting that resident into 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 facility policy, clinical record review, and interview, the facility failed to have a physician order and care plan with specifications relating to size of suprapubic catheter (a thin, flexible tube inserted into the bladder through a small hole in the lower belly to drain urine) and balloon inflation amount (secures catheter to bladder) for one of three residents (Resident R1).Findings include: Review of the facility policy Indwelling Catheter Use and Removal last reviewed 1/2/25, indicated the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/17/25, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (the heart doesn't pump…

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 observations and staff interview, it was determined that the facility failed to provide a dignified dining experience for one of three unit dining rooms observed. (Carondelet Resident R14), and failed to protect and value residents' private space ([NAME] Resident R110, R215, and Fontbonne Resident R8) Findings include: Review of the facility policy Resident Rights dated 1/2/25, indicated that residents have the right to be treated with respect and dignity. During an observation of the Carondelet dining room on 2/24/25, at 11:54 p.m. it was revealed that Resident R14 was being assisted with lunch. Employee E19 was standing beside Resident R14 while feeding her. During an interview on 2/24/25, at 12:25 p.m. Employee E19 confirmed the facility failed to provide a dignified dining experience for Resident R14. During an observation on [NAME] Unit on 2/24/25, at 12:09 p.m. Nurse Aide (NA) Employee E20 was seen entering Resident 110's room without knocking or requesting permission to enter. 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, 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 five residents sampled with facility-initiated transfers (Residents R29, R70, R75, Closed Resident Record CR265, and Closed Resident Record CR266). Findings include: Review of facility policy Transfer and Discharge (Including AMA) dated 1/2/25, indicated for a transfer to another provider, for any reason, the following must be provided to the receiving provider: contact information of the practitioner who was responsible for the care of the resident, resident representative information, advance directive information, all other information necessary to meet the resident's needs, all special instructions and/or precautions for ongoing care, the resident's comprehensive care plan, and all other information necessary to meet the resident's needs. Review of the 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 review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for five of five resident hospital transfers (Residents R29, R70, R75, Closed Resident Record CR265 and Closed Resident Record CR266). Findings include: Review of facility policy Bed Hold Policy dated 1/2/25, indicated the facility will have a process in place to ensure residents and/or their representatives are made aware of the facility's bed-hold policy and reserve bed payment policy well in advance of being transferred to the hospital or when taking therapeutic leave of absence from the facility. In the event of an emergency transfer of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies, as stipulated in the State's plan. Review of the clinical record…

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 care plans that included instructions to provide person centered care for three of ten residents (Resident R49, R228, and R314). Findings include: Review of facility's policy Care Plan Revisions Upon Status Change dated 1/2/25, indicated the facility is to provide a process for reviewing and revising the care plan. Care plans may be modified as needed by a staff member. The care plan will be updated with the new or modified interventions. Review of the clinical record revealed that Resident R49 was admitted to the facility on [DATE]. Review of Resident R49's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/16/25, indicated diagnoses of high blood pressure, septicemia (an infection of the blood), heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Resident R49's care plan dated 2/9/25, failed to reveal 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 observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for three of three crash carts. Findings include: During an observation of the Ebensburg crash cart (a cart maintained with equipment used in cardiac emergencies) on 2/27/25, at 9:58 a.m. revealed a clipboard on the crash cart containing a Crash Cart Check List for February 2025. Review of the check list sheet documentation failed to reveal that the cart was checked on 2/11/25, and 2/15/25. During an interview on 2/27/25, Licensed Practical Nurse (LPN) Employee E9 confirmed the above observation. During an observation of the Fontbonne crash cart on 2/27/25, at 10:09 a.m. revealed a clipboard on the crash cart containing a Crash Cart Check List for February 2025. Review of the check list sheet documentation failed to reveal that the cart was checked on 2/5/25, 2/6/25, and 2/19/25. During an interview on 2/27/25, at 10:11 a.m. Registered Nurse (RN) Employee E8 confirmed the above observation. 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 clinical record, and staff interview, it was determined that the facility failed to develop a baseline care plan that included Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death) interventions needed to provide effective and person-centered care for two of ten residents (Resident R49 and R314). Findings include: Review of the clinical record revealed that Resident R49 was admitted to the facility on [DATE]. Review of Resident R49's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/16/25, indicated diagnoses of high blood pressure, septicemia (an infection of the blood), heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Resident R49's baseline care plan dated 2/9/25, failed to include that the resident had a Life Vest. Review of the clinical record indicated Resident R314 was admitted to the facility on [DATE]. Review of Resident R314's MDS dated [DATE], indicated diagnoses 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 clinical records and staff interview, it was determined that the facility failed to revise a care plan for two of seven residents (Resident R70 and R90) to accurately reflect the current status of the resident. Findings include: Review of clinical record indicated Resident R70 was admitted [DATE], with diagnoses which included sepsis (condition that occurs when the body's immune system overreacts to an infection), bacterial pneumonia and dysphagia (swallowing difficulties). A review of Resident R70's Minimum Data Set (MDS-a periodic assessment of resident care needs) dated 2/3/25, indicated diagnoses remained current. Review of Resident R70's physician orders dated 1/23/25 indicated 1500cc fluid restriction, allergic to fish/shellfish. Review of Resident R70's Resident Care Plan dated 2/3/25, was not updated to include fluid restriction or allergy. During an interview on 2/26/25, at 11:15 a.m. Registered Dietetic Technician Employee E14 confirmed the facility failed to revise care plan for Resident R70…

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 clarify a physician's order for four of seven sampled residents (Resident R49, R57, R70, and R314). Findings include: Review of clinical record revealed a Printable Discharge Form dated 2/6/25, that included correspondence between the facility and the discharging hospital, that stated that Resident R49 will be getting a Life Vest (a wearable defibrillator designed to protect from sudden cardiac death) on discharge. Review of the clinical record revealed that Resident R49 was admitted to the facility on [DATE]. Review of Resident R49s MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/16/25, indicated diagnoses of high blood pressure, septicemia (an infection of the blood), heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Resident R49's clinical record revealed a Nursing Progress note dated 2/10/25, that stated Life Vest…

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, observation, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for two of four residents (Resident R35, and Closed Resident Record CR265). Findings include: Review of the facility policy Wound Treatment Management last reviewed 1/2/25, indicated that wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Review of facility policy Pressure Injury Prevention Guidelines dated 1/2/25, indicated interventions will be documented in the care plan and communicated to all relevant staff. Review of the clinical record revealed that Resident R35 was admitted to the facility on [DATE]. Review of Resident 35's MDS…

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

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 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 (Residents R90). Findings include: Review of facility policy Enteral Feeding dated 1/2/25, indicated enteral feedings may be prescribed who are physically or psychologically unable to take food by mouth in amounts that will support adequate nutrition. Review of Resident R90's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R90's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/11/25, indicated diagnoses of high blood pressure, cancer (uncontrolled growth and spread of abnormal cells), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). MDS section…

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 a complete order for a resident with a tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube), failed to obtain a physician order for use of a CPAP machine (a form of non-invasive ventilation (NIV) therapy used to facilitate breathing), and failed to develop a plan of care for two of five residents (Resident R90 and Closed Resident Record CR264). Findings include: Review of facility policy Noninvasive Ventilation (CPAP, BiPAP, Trilogy) dated 1/2/25, indicated the facility will obtain an order for the use of a CPAP, BiPAP or Trilogy device and settings from the practitioner. Review of Resident R90's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R90's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/11/25, indicated diagnoses of…

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

Based on review of resident clinical records and staff interview, it was determined the facility failed to provide consistent and complete communication with the dialysis (treatment that helps body remove extra fluid and waste products) center for one of one resident receiving hemodialysis (Resident R165) for two of four days. Findings include: A review of Resident R165's MDS (MDS-a periodic assessment of resident care needs) dated 2/14/25, with the diagnosis of end stage renal disease (permanent condition in which the kidneys can no longer filter the blood), diabetes mellitus and abnormalities of gait and mobility. A review of Resident R165 physician orders last revised on 2/10/25, indicate dialysis Mondays, Wednesdays and Fridays. A review of Resident R165's dialysis binder indicated dialysis sheets completed on 2/10/25 and 2/17/25, incomplete 2/19/25 and 2/24/25. During an interview on 2/26/25, Registered Nurse Employee E15 confirmed the dialysis communication forms were incomplete for two of four days. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code…

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 upon review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that any irregularities submitted in the medication regimen reviews (MRR) by pharmacy were acted upon timely for one out of three residents (Resident R75). Findings include: Review of facility policy Medication Monitoring dated 1/2/25, indicated comments and recommendations concern drug therapy are communicated in a timely fashion. A summary of all recommendations is provided to the Director of Nursing and Facility Medical Director every month. The timing of these recommendations should enable a response prior to the next drug regimen review. The consultant pharmacist and the facility follows up on his/her recommendations to verify that appropriate action has been taken. Review of the clinical record indicated Resident R75 was admitted to the facility on [DATE]. Review of Resident R75's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/4/25, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies in one of three medication carts (Ebensburg Second Hall Med Cart). Findings: Review of facility Medication Storage in facility policy dated [DATE], indicated that medications and biologicals are stored safely, securely, and properly, following manufacturer ' s recommendations or those of the supplier. Narcotics are stored in a separate area under double lock. Expiration dates included: Humalog and Glargine Insulin expires 28 days after opened. During a medication cart review on [DATE], at 9:51 a.m. the narcotic lock box on the Ebensburg Second Hall medication cart was not locked. The medication cart also included: - Humalog Insulin Pen (used to treat diabetes - a metabolic disorder in which the body has high sugar levels for prolonged periods of time) that was expired. - Insulin Glargine Pen (used to treat diabetes) that did not have an opened date on it. 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.

Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to ensure that nursing staff had the specific competencies and skill set necessary to provide care for residents with a Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death). Findings include: The signed job description for Nursing Home Administrator dated 1/31/19, indicated that this position leads a team of professionals and directs the daily operations of the facility in all departments to assure the provision of high-quality care/services making sure that the medical, physical, social, and emotional needs and general welfare of residents are met. The signed job description for Director of Nursing dated 1/2/19, indicated the purpose of this position is to plan, organize, develop, and direct the overall operation of the Nursing Service Department in accordance with current Federal, State, and local standards, guidelines, and regulations that govern the facility to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and a review of the facility's assessment it was determined that the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for its specific resident population. Findings include: Review of the facility policy Facility Assessment, dated 1/2/25, indicated that the facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operation and emergencies. The facility's resident population, including but not limited to the staff competencies that are necessary to provide the level and types of care needed for the resident population. Review of clinical record revealed a Printable Discharge Form dated 2/6/25, that included correspondence between the facility and the discharging hospital, that stated that Resident R49 will be getting a Life Vest (a wearable defibrillator designed to protect from…

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, resident clinical records, and staff interview, it was determined the facility failed to identify a hospice provider in physician orders and failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for two of three residents (Residents R59 and R90). Finding include: Review of facility policy Hospice Services Facility Agreement dated 1/2/25, indicated a facility designee will work with the hospice representative and is responsible for obtaining physician certification and recertification of the terminal illness specific to each resident and instructions on how to access the hospice's 24-hour on-call system. The facility will, under a written agreement, ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial…

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 interviews, it was determined that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of two residents (Resident R8). Findings include: The Centers for Disease Control defines Enhanced Barrier Precautions (EBP) as: an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involve gown and gloves during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Review of the facility policy Enhanced Barrier Precautions Procedure dated 1/2/25, indicated the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. EBP refer to the use of gown and gloves for use during high-contact 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 review of facility policy, facility documentation, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents were free from verbal abuse for one of three residents (Resident R50). Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 1/5/24, indicated verbal abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability. 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 12/13/23, indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and Multiple Sclerosis (a disease that affects the central nervous system). Review of a Health Status Note dated 3/7/24, 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 Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for two out of five sampled resident records (Residents R76 and R80). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated the following instructions for Section V Care Area Assessment (CAA) Summary, Questions V0200: For each triggered Care Area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. The Care Planning Decision column must be completed within 7 days of completing the RAI (MDS and CAA(s)). Check column B if the triggered care area is addressed in the care plan. Review 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 facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure appropriate treatment and services were provided for one of four residents (Resident R2) with an indwelling catheter (a tube inserted in the bladder to drain urine). Findings include: Review of facility policy Catheter Care dated 1/5/24, indicated residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/24, indicated diagnoses of urinary tract infection, retention of urine, and diabetes (too much sugar in the blood). Review of a physician's order dated 2/12/24, indicated to change catheter and catheter bag as needed for leakage or blockage. Review of a Health Status Note dated 2/19/24, Registered Nurse…

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, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for two of five residents reviewed (Resident R2 and R315). Findings include: Review of the facility policy Oxygen Concentrator dated 10/17/22, last reviewed on 1/5/24, indicated change oxygen tubing mask/cannula weekly and as needed if it becomes soiled or contaminated. If applicable, change the nebulizer tubing and delivery device every seventy-two hours or as recommended by the manufacture. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/24, indicated reentry to facility on 2/12/24, with the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), heart failure (heart doesn't pump blood as well as it should), chronic obstructive pulmonary disease (COPD - makes breathing hard). Review of Resident R2's physician order dated 6/30/23, indicated Arformoterol Tartrate Inhalation…

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 interviews, it was determined that the facility failed to properly store medical supplies and biologicals in one of three medication carts and failed to properly secure medications and/or biologicals for two of six residents. Findings include: Review of the facility policy Medication Storage dated 10/17/22, last reviewed 1/5/24, indicates compliance guidelines including but not limited to: - During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. - External products: disinfectants and drugs for external use are stored separately from internal and injectable medications. Findings include: Review of Resident R329's medical record indicated an admission date of 3/1/24, with diagnosis of chronic obstructive pulmonary disease (COPD-difficulty breathing), diabetes (high blood sugar), hypertension (high blood pressure). Review of Resident R329's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly disinfect reusable equipment between residents for one of four nursing units observed ([NAME] Unit) and failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R85). Findings include: Review of facility policy Glucometer Disinfection indicated the facility will ensure blood glucometers (a device used to check blood sugar levels) will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. The glucometers will be a wipe pre-saturated with an EPA (Environmental Protection Agency) registered healthcare disinfectant that is effective against HIV (Human Immunodeficiency Virus), Hepatitis C and Hepatitis B virus. Review of the EvenCare G3 Blood Glucose Monitoring System manual indicated the following approved products for cleaning and disinfecting 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 records, facility documents, and staff interview, it was determined that the facility failed to fully investigate injuries of unknown origin for one of four residents reviewed (Resident CR1). Findings include: A review of the facility's Abuse, Neglect, and Exploitation policy dated 10/17/22, last reviewed 12/31/22 indicated an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. It states physical injury of a resident of unknown source is a possible indicator of abuse. It was indicated the facility must identify and interview all persons, including alleged victim, alleged perpetrator, witnesses and other who might have knowledge of the allegations. It was indicated complete and thorough documentation of the investigation must be provided. Review of the facility's Incidents and Accidents policy dated 10/17/22, last reviewed 12/31/22, indicated it is the facility's policy to utilize…

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.