Beaver Valley Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, facility documents, and staff interviews it was determined that the facility failed to identify a seat belt and table attached to a wheelchair and leg straps placed over a residents thighs as a possible restraint, and failed to assess the functional status of the individual residents to determine if the use of a seatbelt or table attached to a wheelchair and leg straps placed over a residents thighs is a restraint for two of four residents (Residents R15 and R58). Findings include: Review of facility policy Use of Restraints dated 7/11/25, stated restraints shall only be used to treat the resident's medical symptom and never for discipline or staff convenience, or for the prevention of falls. Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that each resident's drug regimen was free from unnecessary psychotropic drugs used without adequate indications for use for one of three residents (Resident R98).Findings include: Review of Resident R98's admission record indicated she was initially admitted to the facility on [DATE]. Review of Resident R98's Minimum Data Set (MDS- periodic assessment of care needs) assessment dated [DATE], included diagnoses of depression, metabolic encephalopathy (a change in how your brain works due to an underlying condition), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). No psychotic diagnoses were present on the MDS. Review of Section N: Medications revealed Resident R98 received antipsychotic medications in the seven days prior to the assessment. Review of the facility diagnoses list indicated, dementia in other diseases classified…

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 documentation, review of clinical records and staff interview it was determined that the facility failed to ensure an appropriate discharge for one of three residents and failed to notify the ombudsman of the correct living arrangement for one of three residents (Closed Record Resident R131). Findings include: Review of Closed Record Resident R131 was admitted on [DATE]. Review of Closed Record Resident R131 MDS (minimum data set - a periodic assessment of resident needs) dated 3/23/25, indicated diagnosis of anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation) hyperlipidemia (excess of lipids or fats in your blood), and respiratory failure (is a condition where there is not enough oxygen or too much carbon dioxide in the body). Review of facility documentation indicated that Closed Record Resident R131 on 4/2/25, was found in the parking lot with what appeared to be aluminum foil shaped into what…

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 Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for one of four residents (Resident R8).Findings include: Review of the facility policy Certifying Accuracy of the Resident Assessment last reviewed 7/11/25, indicated any person completing a portion of the Minimum Data Set (MDS-resident assessment instrument) must sign and certify the accuracy of that portion of the assessment. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's MDS dated [DATE], indicated diagnoses of heart failure (heart doesn't pump the way it should), anxiety and depression. Section P0100 Physical Restraints used in bed: A-Bed rail coded as used daily. Review of the facility provided resident matrix on 9/22/25, indicated Resident R8…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop a baseline care plan for one of three residents (Resident R4).Findings include: Review of facility policy Care Plans-Baseline last reviewed 7/11/25, indicated a baseline plan of care to meets the resident's immediate needs shall be developed for each resident within forty-eight hours of admission. The baseline care plan will be used until the staff can conduct the comprehensive assessment and interdisciplinary person-centered care plan. Review of the clinical record revealed Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/6/25, indicated diagnoses of anemia (low iron in the blood), high blood pressure, and diabetes (high sugar in the blood). Review of Resident R4's admission evaluation section 9 baseline care plan/order review was checked no. During an interview completed on 9/24/25, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, review of clinical record, observation, and resident and staff interview, it was determined that the facility failed to provide appropriate foot care to one of six residents (Residents R15).Findings include: The facility's Foot Care dated 7/11/25, stated residents will receive appropriate care and treatment in order to maintain mobility and foot health. Residents will be assisted in making transportation appointments to and from specialist (podiatrists) as needed. Review of the admission record indicated Resident R15 was admitted to the facility on [DATE]. Review of Resident R15's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/3/25, indicated diagnoses of high blood pressure, cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced), and muscle weakness. Review of Resident R15's physician order dated 6/3/25, indicated to consult podiatry for toenail trim. During an interview and observation on 9/23/25, at 10:37 a.m. Resident R15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and documents, clinical records, and staff interviews, it was determined that the facility failed to provide prescribed treatment and services related to the care of a PICC line (peripherally inserted central catheter, a long, thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) for two of two residents (Resident R16 and R42).Review of the clinical record indicated Resident R16 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R16's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/2/25, indicated diagnoses of high blood pressure, diabetes (high sugar in the blood) and encounter for orthopedic aftercare following surgical amputation. Review of Resident R16's care plan dated 8/27/25, indicated to change IV site dressing per physician order and as needed if soiled or wet. Review of Resident R16's physician order dated 9/10/25, stated to change the PICC dressing and caps…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to make certain consistent dialysis communication was maintained for one of two residents (Residents R89) and ensured fluid restrictions were maintained for one of two residents (Resident R89).Findings include: Review of the facility policy Encouraging and Restricting Fluids last reviewed 7/11/25, indicated to provide the resident with the amount of fluids necessary to maintain optimum health this may include encouraging or restricting fluids. The following information should be recorded in the resident's medical record that includes but not inclusive to the amount in millimeters of fluids consumed by the resident during the shift. Review of the clinical record indicated Resident R89 was admitted to the facility on [DATE]. Review of Resident R89's MDS assessment dated [DATE], indicated the diagnosis of diabetes (high sugar in the blood), hemiplegia affecting right side and dependence on renal…

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 record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R1).Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with the diagnosis of Post Traumatic Stress Disorder (PTSD-a mental health condition in people who have experienced or witnessed a traumatic event), diabetes (high sugar in the blood) and heart failure (heart doesn't pump the way it should). Review of R1's minimum data assessment (MDS- periodic assessment of resident care needs) dated 8/2/25, indicated diagnosis are current. Review of Resident R1's care plan dated 7/18/22, indicated - At risk for changes in mood related to bipolar disorder, post-traumatic stress disorder chronic, agoraphobia with panic disorder, anxiety disorder. The care plan failed to identify PTSD…

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, clinical record and staff interview it was determined that the facility failed to provide medically related social services for one of three residents reviewed (Closed Record Resident R131).Findings include: Review of Closed Record Resident R131 MDS (minimum data set - a periodic assessment of resident needs) dated 3/23/25, indicated diagnosis of anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation) hyperlipidemia (excess of lipids or fats in your blood), and respiratory failure (is a condition where there is not enough oxygen or too much carbon dioxide in the body). Review of facility documentation indicated that Closed Record Resident R131 on 4/2/25, was found in the parking lot with what appeared to be aluminum foil shaped into what appeared to be pipe and a white substance. Review of clinical record follow up dated 4/11/25, indicated: Past Medical History: Active Medical Problems: Opioid dependence - Drug use history of Assessment and Plan: 1. Opioid…

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 interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for two of five residents reviewed (Residents R89 and R91).Findings include: Review of the facility policy Medication Administration-General Guidelines last reviewed 7/11/25, indicated that medications are administered as prescribed in accordance with good nursing principles and practices. Medications are administered in accordance with written orders of the attending physician. Review of the facility policy Administering Medications last review 7/11/25, indicated medications are administered in accordance with prescriber orders. Medication administration times are determined by resident need and benefit, not staff convivence. Review of the facility policy Insulin Pen Administration las reviewed 7/11/25, indicated to administer insulin subcutaneously using a pen in a safe, accurate and effective manner. Procedure steps…

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 facility policy review, review of the Quality Assurance attendance records, and staff interview it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required members for one of three quarters (Quarter one of 2025). Findings include: The facility policy Quality Assurance and Performance Improvement (QAPI) Plan dated 7/11/25, indicated This facility shall develop, implement and maintain an on-going, facility wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, purse methods to improve care quality, and resolve identified problems. Review of Quality Assurance and Performance minutes sign in sheets and attendance records for Quarter One of 2025, failed to reveal the Medical Director was in attendance. During an interview 9/26/25, at 1:15 p.m. NHA (Nursing Home Administrator confirmed that the facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly with all the required committee members for one of three quarterly…

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, closed resident clinical records, facility documents, staff interviews, it was determined that the facility failed to report an allegation of sexual abuse for one of five sampled residents (Closed Resident Record CR1). Findings include: The facility Abuse investigation and reporting policy last reviewed on 8/1/24, indicated that all reports of resident abuse, neglect , exploitation, and misappropriation of resident property shall be promptly reported to the local, state and federal agencies and thoroughly investigated by facility management. If an incident or suspected incident of resident abuse is reported, Administration will assign the investigation to an appropriate individual. The Administrator will provide any supporting documentation, will keep the resident or resident representative informed, and will ensure any further abuse is prevented. The assigned investigator will record the results of the investigation. An alleged violation of abuse will be reported. 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, closed clinical records and staff interviews, it was determined that the facility failed to make certain allegations of abuse are thoroughly investigated for one of five sampled residents (Closed Resident Record CR1). Findings include: The facility Abuse investigation and reporting policy last reviewed on 8/1/24, indicated that all reports of resident abuse, neglect , exploitation, and misappropriation of resident property shall be promptly reported to the local, state and federal agencies and thoroughly investigated by facility management. If an incident or suspected incident of resident abuse is reported, Administration will assign the investigation to an appropriate individual. The Administrator will provide any supporting documentation, will keep the resident or resident representative informed, and will ensure any further abuse is prevented. The assigned investigator will record the results of the investigation. An alleged violation of abuse will be reported. 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 observations, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of three residents (Residents R96). Findings include: Review of the facility policy Self-Administration of Medication dated 8/1/24, indicated residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Self-administered medications must be stored in a safe and secure place. Review of the admission record indicated Resident R96 was admitted to the facility on [DATE], with diagnosis that include acute kidney failure (kidneys suddenly can't filter waste), anemia (low iron in the blood), and hypertension (high blood pressure). Observation on 9/3/24, at 10:26 a.m. Resident R96 was sitting on the edge of bed. A box of Ivizia eye drops (used for dry eyes) were noted to her bedside stand. During an interview on 9/3/24 at 10:43 a.m. Licensed Practical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, resident records and staff interview, the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two out of two residents sampled with facility-initiated transfers (Resident R21 and R60). Finding include: Review of the facility policy Transfer or Discharge Documentation dated 8/1/24, indicated when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provided. When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: ·The basis for transfer or discharge ·Disposition of medication ·Summary of the resident's overall medical, physical, and mental condition ·That an appropriate notice was provided to the resident and /or legal representative ·All special instructions or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within twenty-four hours of transfer for two of two residents (Residents R21 and R60). Findings include: Review of the facility policy Bed Hold, dated 8/1/24, indicated that the facility is required to notify responsible party of the Bed Hold options and associated financial liability: 1) At the time of admission to ensure that the Resident/Responsible Party is aware of the procedure to be followed to guarantee a bed upon returning from a future leave. 2) Each time a resident will be absent from the facility for hospitalization or other medical or therapeutic leave so that the Resident and/or Responsible Party may make a choice to either hold the bed or discharge from the facility for the…

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

Based on review of facility policy, resident observations, clinical record review and staff interviews, it was determined that the facility failed to develop a plan of care to include a focus and interventions to maintain a resident's highest practicable physical well-being as required for one of three residents. (Resident R28) Findings include: Review of the facility Care Plans, Comprehensive Person Centered policy dated 8/1/24, indicates a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of Resident R28's Minimum Data Set (MDS-periodic assessment of care needs) dated 7/23/24, indicated a re-entry to facility on 10/17/22, with diagnoses of heart failure (heart doesn't pump as well as it should), hypertension (high blood pressure), and diabetes (high sugar in the blood). Observation 9/3/24, at 10:40 a.m. resident R28 was sitting next to his bed and was noted to have bilateral skin sleeves on. A review of Resident R28's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident had a physician order for treatment residents were receiving for two of five residents (Resident R28 and 260). Findings include: Review of facility policy Therapeutic Diets dated 8/1/24, indicated therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with the resident's goals and preferences. Diet order should match the terminology used by the food and nutrition services department. Review of the facility policy Medication and Treatment Orders dated 8/1/24, indicates orders for medications and treatments will be consistent with principles of safe and effective order writing. Drugs and biologicals orders must be recorded on the Physicians orders sheet. Review of Resident R28's Minimum Data Set (MDS-periodic assessment of care needs) dated 7/23/24, indicated a re-entry to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interviews, it was determined that the facility failed to make certain that appropriate treatment and services were ordered and/or provided for two of three residents with a urinary catheter (Resident R37 and R260). Findings include: Review of the facility policy Medication and Treatment Orders dated 8/1/24, indicates orders for medications and treatments will be consistent with principles of safe and effective order writing. Review of the facility policy Catheter Care, Urinary last reviewed 8/1/24, indicate check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter tubing free of kinks, the drainage bag must be held or positioned lower that the bladder at all times. Review of the facility policy Resident Rights last reviewed 8/1/24, these rights include the residents right to a dignified existence, to be treated with respect, kindness, and dignity. Review of Resident R37's Minimum Data Set (MDS - a periodic assessment…

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 one of three residents reviewed (Resident R51). Findings include: Review of the facility policy Oxygen Administration dated 8/1/24, indicates the purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in procedure include but not limited to: -Be sure there is water in the humidifying jar and the water level is high enough that the water bubbles as oxygen flows. -Periodically re-check water in humidifying jar. Review of the facility policy Administering Medications through a Small Volume (handheld) Nebulizer dated 8/1/24, indicates the purpose of the procedure is to administer particles of medication safely and aseptically into the resident's airway. Steps in procedure include but not limited to: -When treatment is completed, turn off nebulizer and disconnect T-piece, mouthpiece, and medication cup. -Rinse and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents (Resident R36, and R84). Findings include: Review of facility policy Trauma Informed Care dated 8/1/24, indicated that trauma-informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. Review of the clinical record indicated Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/26/24, indicated diagnoses of Post…

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 observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing assessments to ensure that bed rails were used to meet residents' needs and the risks associated with bed rail usage for two of five residents (Residents R51 and R79). Findings include: Review of Title 42 Code of Federal Regulations (CFR) §483.25(n) - Bed Rails states that the facility must assess the resident for risk of entrapment from bed rails prior to installation. Additionally, there should be evidence in the resident's records that the facility performed ongoing assessments to assure that the bed rail is used to meet the resident's needs and that there is an ongoing evaluation of risks associated with bed rail usage. Review of the facility policy Proper Use of Side Rails dated 8/1/24, indicated the resident will be checked re-evaluated relative to side rail use quarterly, annually and with a change in condition. Review of the admission 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.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals properly and securely in one of three medications carts (one [NAME] medication cart). Findings include: Review of the facility policy Medication Storage in the Facility last reviewed 8/1/24, indicated medications and biologicals are stored safely, securely, and properly, following manufactures recommendations or those of the supplier. During an observation on 9/4/24, at 9:18 a.m. it was revealed that the one [NAME] medication cart contained: . One vial of artificial tears, that failed to have name or date opened. . One vial fluticasone nasal spray that failed to have date opened. . One bottle lactulose solution that failed to have date opened. . One anora ellipta inhaler that failed to have date opened. . One bottle of opened pure leaf tea. . Two cans of Arizona herbal tonic energy drink. . One medicine cup labeled with the initial H that contained: . One brown capsule . Four white tablets . One beige tablet . One tan gel filled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records, observation, and staff interviews, it was determined that the facility failed to implement infection control monitoring and management during a COVID-19 outbreak for one out of two residents (Resident R6) and failed to prevent cross contamination during a dressing change for one of three residents (Resident R13). Finding include: Review of facility policy SARS-CoV-2 Management dated 8/1/24, indicated the facility follows current guidelines and recommendations for managing COVID-19 in the facility. Anyone with even mild symptoms of COVID-19 (fatigue, headache, sore throat, fever, chills, etc.), regardless of vaccination status, should receive a viral test as soon as possible. It was indicated as part of the broad-based approach during an outbreak, testing should continue on affected units or facility-wide every 3-7 days until there are no new cases for 14 days. Testing should be performed for all residents and staff identified as close contacts or 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical records, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two of three residents (Resident R1, and R9). Findings Include: A review of the facility policy Transfer and discharge- 30 day last reviewed 7/9/24, indicated a resident/representative will be notified in writing the reason for the transfer or discharge using the notice of transfer or discharge form, this includes sending a copy to the Office of the Long-Term Care Ombudsman A review of Resident R1's clinical record indicates admission date of 7/12/24, with the diagnoses of Vascular Dementia with agitation (decline in thinking skills caused by reduced blood flow), Urinary tract infection (infection in the urinary system), and Hypertension (high blood pressure). A review of Resident R1's clinical record revealed that the resident was transferred to the hospital on 7/15/24, and has not returned 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 reviews and staff interviews, it was determined that the facility failed to permit the readmission of a hospitalized resident without providing evidence that the facility was not able to meet the resident's needs for one of three residents reviewed (Resident R1). A review of the facility policy Transfer and discharge- 30 day last reviewed 7/9/24, indicated a resident and/or his or her representative (sponsor), will be given a thirty-day advanced notice of an impending transfer or discharge from facility. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge. The transfer is necessary for the resident ' s welfare and the resident ' s needs cannot be met in the facility. A review of Resident R1's clinical record indicates admission date of 7/12/24, with the diagnoses of Vascular Dementia with agitation (decline in thinking skills caused by reduced blood flow), Urinary tract infection (infection in the urinary system),…

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

Based on review of facility policy and resident interviews and observations, it was determined that the facility failed to ensure sufficient staffing to meet resident need for eight of twelve residents (Resident R1, R2, R3, R4, R5, R6, R7, and R8). Findings include: Review of the facility policy, Answering the Call Light dated 7/13/23, indicated the facility will provide timely responses to the resident's requests and needs. During an interview on 7/15/24, at 10:22 a.m. Resident R1, when asked if she felt the facility had sufficient staff stated, probably not. Observation at this time revealed Resident R1 to have unbrushed, greasy appearing hair. Review of Resident R1's shower record from 6/17/24, through 7/17/24, revealed two showers provided (7/12/24, and 7/17/24). No bed baths were documented, and no refusals of bathing were documented. Review of census information revealed Resident R1 was present in the facility during the review dates. During an interview and observation on 7/15/24, at 10:27 a.m. Resident R2 was noted to be wearing a hospital gown. When asked if she preferred…

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 policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility (Main Kitchen). Findings include: A review of facility policy Sanitization dated 7/13/23, indicated that the food service area is maintained in a clean and sanitary manner. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solution. During an observation conducted on 9/25/23, at 10:40 a.m., of the walk-in cooler in the designated main kitchen of the facility revealed that cold air condenser fan covers and the ceiling immediately forward of these cooler fans had a build-up of dust, grime, and debris. During an interview conducted on 9/25/23, at 10:41 a.m., Food Service Manager (FSM) Employee E11 confirmed that the walk-in cooler fan covers and the ceiling immediately forward of the cooler fans had a built-up of dust, grime, and debris as observed with surveyor. 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 facility policy, a resident council group interview, observations and staff interview it was determined that the facility failed to maintain proper ventilation for two out of two Resident Central Shower Rooms (First and Second Floors). Findings include: The facility Resident rights policy, last reviewed on 7/13/23, indicated that the residents have the right to a comfortable environment. The resident council group interview on 9/26/23, at 11:00 a.m. indicated two of the eleven residents present stated that they can't breathe easily in the shower rooms on the first and second floor due to the lack of ventilation and air circulation. Observations on 9/26/23, at 1:00 p.m. of the second floor shower room indicated three shower stalls with three separate vents at the ceiling level. The vents were not on. Observations on 9/28/23, at 11:00 a.m. of the first floor shower room indicated three shower stalls with three separate vents at the ceiling level. The vents were not on. Interview on 9/28/23, at 11:35 a.m. Nursing Assistant (NA) Employee E6 indicated the vents haven't…

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 observations, review of federal regulations, facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for four of four residents (Residents R4, R13, R20, and R69). Findings include: Review of Title 42 Code of Federal Regulations (CFR) §483.25(n) - Bed Rails states that the facility must assess the resident for risk of entrapment from bed rails prior to installation. Additionally, there should be evidence in the resident's records that the facility performed ongoing assessments to assure that the bed rail is used to meet the resident's needs and that there is an ongoing evaluation of risks associated with bed rail usage. Review of facility policy Bed Safety dated 3/1/22, and 7/13/23, indicated side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed 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 review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for three out of five nurse aide personnel records (Nurse aides (NA) Employee E2, NA Employee E3, and NA Employee E4). Findings include: The facility Performance evaluations policy last reviewed on 7/13/23, indicated that the job performance of each employee shall be reviewed and evaluated at least annually. Review of Nurse Aide (NA) Employee E2's personnel record indicated she was hired to the facility on [DATE]. Review of Nurse Aide (NA) Employee E3's personnel record indicated she was hired to the facility on [DATE]. Review of Nurse Aide (NA) Employee E4's personnel record indicated she was hired to the facility on 7/3/06. Review of personnel records did not include an annual performance evaluations based on the date of hire for Nurse Aide (NA) Employee E2, Nurse Aide (NA) Employee E3, and Nurse Aide (NA) Employee E4. During an interview on 9/27/23, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of four dialysis residents. (Resident R58 and R61). Findings include: Review of CMS guidelines, 483.25(1) states the facility assures that each resident receives care and services for the provision of dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) including the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments. Review of the admission record indicated Resident R58 was admitted to the facility on [DATE]. Review of Resident R58's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/11/23, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and renal failure (condition where the kidneys lose…

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

Based on review of facility policy, observations and staff interview it was determined that the facility failed to date opened medications and properly store medications in one of three medication carts observed (North Hall second floor cart). Findings include: Review of facility policy Storage of Medications reviewed on 7/13/23, indicated resident medications are stored separately from each other to prevent the possibility of mixing medications between residents. Review of facility policy Medication Labeling and Storage reviewed on 7/13/23, indicated multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Observation on 9/27/23, at 11:07 a.m. the second floor North Hall medication cart indicated the following medications stored in one compartment without individual packaging or separation from other residents medications: -Resident R73's Basaglar Pen (prefilled pen to inject long acting insulin under the skin) and vial of NovoLog (rapid acting insulin) not in a box or…

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