Friendship Rehab and Health

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 maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for seven of seven residents (Residents R5, R6, R17, R87, R108, R124, and R190). Findings include: Review of the facility policy Enabler Bars last reviewed 10/1/25, indicated the use of enabler bars or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of enabler bars have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/21/25, indicated diagnoses of diabetes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRRs) were completed by the facility for five of seven residents (Resident R3, R6, R97, R133 and R137), and failed to ensure MRRs were reviewed by the resident's attending physician monthly for one of seven residents (Resident R7).Findings include: The Pharmacy Service policy last reviewed 10/1/25, indicated the nursing home shall have pharmaceutical services that meet the needs of the residents. A licensed pharmacist will review the drug regimen reviews of each resident at least monthly. The pharmacist will report any irregularities to the attending physician and the Director of Nursing (DON) they will sign off and/or address the report in their progress note. Review of the clinical record indicated Resident R97 was admitted to the facility on [DATE]. Review of Resident R97's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/22/26,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in three of four medication rooms (2 East Medication Room, 3 East Medication Room, and 5 Main Medication Room), and one of eight medication carts (3 East units [NAME] Hall Medication Cart) and failed to properly secure one of eight medication carts (3 East units [NAME] Hall Medication Cart) while not in use.Findings include: Review of facility policy Storage of Medications dated 10/1/25, indicated medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. No discontinued, outdated or deteriorated medications are available for use in the facility. All such medications are destroyed. Compartments containing medications are locked when not in use. During an observation on 3/9/26, at 12:32 p.m. of the 5 Main Medication Room, an opened bottle of tuberculin solution (a medication administered to test…

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

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to properly contain and dispose of garbage in two of two outside dumpsters to prevent the potential for rodent and insect infestation (dumpster one, and dumpster two).Findings include: Review of the facility policy Garbage and Rubbish Disposal, dated 10/1/25, indicated that outside dumpsters provided by the garbage pick-up services must be kept closed and free of litter around the dumpster area. During an observation and interview of the facility's outdoor trash receptacles on 3/10/26, at 1:30 p.m. Dietary Manager Employee E19 confirmed that the lid/cover was not closed on dumpster one, and dumpster two, and that the facility failed to properly contain and dispose of garbage in the outside trash receptacles to prevent the potential for rodent and insect infestation. 28 Pa. Code 201.18(b)(3) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to prevent cross contamination during a dressing change for one of two residents (Resident R293), failed to prevent cross contamination during a medication pass for one of three residents (Resident R248) and failed to implement appropriate transmission-based precautions for three of six residents (Residents R18, R111 and R276). Review of the facility policy Enhanced Barrier Precautions (EBP) last reviewed 10/1/25, indicated Enhanced Barrier precautions are an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDRO). Enhanced barrier precautions are to be implemented for residents with an infection or colonization with a MDRO, wounds and or indwelling medical devices. An enhanced barrier precaution sign will be displayed near the entrance of the room. Review of the facility policy Wound Care dated 10/1/25, indicated the facility follows…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for two of five residents (Residents R17 and R298).Findings include: Review of facility policy Resident Rights dated 10/1/25, indicated the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Review of the clinical record revealed Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/3/26, indicated diagnoses of high blood pressure, obstructive uropathy (condition in which urine flow is blocked), and hemiparesis (one-sided muscle weakness, often caused by stroke or brain injury). Review of a physician order dated 2/13/26, indicated 16 French (catheter size) foley catheter with 5 cc (cubic centimeter, unit of volume measurement) balloon for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain residents' confidential personal and medical records for one of five residents (Resident R3). Findings include: A review of the facility policy titled, Resident Rights dated 10/1/25, indicated that residents have the right to privacy in treatment and personal care. Review of the clinical record revealed that Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 12/8/25, indicated diagnoses of high blood pressure, hyperkalemia (high levels of potassium in the blood), and chronic pain. During an observation on 3/10/26, at 9:18 a.m. a sign was observed posted on Resident R3's wall above the bed that included the following information: Nectar thick liquids, no thin liquids. Review of Resident R3's clinical record failed to include any documentation that the above residents or their representatives…

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 Manual, clinical records, and staff interview, it was determined that the facility failed to ensure Minimum Data Set (MDS- a periodic assessment of care needs) accurately reflected the resident's status for two of seven residents (Resident R15, R13). Findings include: Review of MDS instructions for Section N Medications N0415F, Antibiotics is to be checked if the resident is taking any medications by pharmacological classification during the last seven days or since admission/entry or reentry if less than 7 days. Resident R13's clinical record revealed an admission date of 12/30/24, with diagnoses including stroke, difficulty speaking, left-sided weakness, and human immunodeficiency virus. Resident R13's Annual MDS with an Assessment Reference Date (ARD) of 1/06/26, Section N0415F was coded yes receiving antibiotics admission/entry or reentry if less than 7 days. Residents R13's clinical record lacked evidence that he/she had received antibiotics…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to incorporate the recommendations from the Pre-admission Screening and Resident Review (PASARR) level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for one of three residents reviewed (Resident 65).Findings include: Review of the clinical record revealed that Resident R65 was admitted to the facility on [DATE]. Review of Resident 65's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/10/26, indicated diagnoses of bipolar disorder (a mental condition marked by alternating periods of elation and depression), anxiety, and depression. Further review of Resident 65's clinical record revealed a PASARR Level I (federally required assessment to help ensure that all individuals with serious mental disorders and/or intellectual disabilities are not inappropriately placed in nursing homes for long term care) dated 5/25/16 with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records, and staff interviews it was determined that the facility failed to include hyperglycemic (high blood sugar) protocols for one of three residents (Resident R6).Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/2/26, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and schizophrenia (a serious mental health condition that affects thinking, feeling and behavior). Review of Resident R6's physician orders dated 11/18/25, indicated Accu-check's (measures blood glucose levels using small blood sample on a test strip) every day and evening shift. Review of Resident R6's physician order dated 11/20/25, indicated Glucose Gel 40 % (Dextrose and water that quickly raises blood sugar levels) give 1 applicator full by mouth as needed…

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, to prevent pressure ulcers (PU/PIs - injuries to skin and underlying tissue resulting from prolonged pressure on the skin), and failed to develop a plan of care timely for one of four residents (Resident R108).Findings include:Review of facility policy Pressure Ulcer - Prevention and Treatment dated 10/1/25, indicated residents will receive skin care, repositioning and nutritional support to assist in preventing the development of avoidable pressure ulcers. Routine preventative and daily care will be provided to prevent avoidable pressure ulcers. Routine preventative care means turning and proper positioning, application of pressure reduction or relief devices, providing good skin care (i.e., keeping the skin clean, instituting measures to reduce…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility and failed to develop and revise a comprehensive resident-specific plan of care for a resident with limited mobility requiring equipment and assistance to maintain or improve mobility for two of five residents (Residents R124 and R307).Findings include: Review of facility policy Care Planning and Implementation dated 10/1/25, indicated each resident will have an individualized interdisciplinary care plan developed that addresses the resident's needs as they are discovered through the assessment process. The overall care plan will be oriented towards preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end of life situation), applying current…

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 clinical records, observations, and staff and resident interviews, it was determined that the facility failed to promote cleanliness and prevent the spread of infection regarding respiratory care equipment for two of four residents reviewed for respiratory care (Residents R8, R98,).Findings include:A facility policy entitled, Oxygen Administration dated 10/01/25, indicated that staff will change pre-filled humidification systems and tubing at least weekly, check concentrator filters for cleanliness and clean as needed with soap and water.Resident R8's clinical record revealed an admission date of 2/13/25, with diagnoses including chronic obstructive pulmonary disease (COPD- long-term, progressive lung disease that obstructs airflow, causing breathlessness, chronic cough, and sputum production), sudden respiratory failure, renal failure, pancytopenia (abnormally low levels of red blood cells, white blood cells, and platelets).A physician's order dated 11/16/25, to administer supplemental oxygen to Resident R8 at two liters/minute (LPM) via nasal…

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, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis (a machine that filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of three residents (Resident R79).Findings include:Review of facility policy Dialysis Care dated 10/1/25, indicated residents ordered dialysis therapy will be monitored and documentation will be maintained in the medical record. All residents receiving dialysis will be assessed before and after dialysis treatment and for compliance with their individualized plan of care. Review of the clinical record revealed Resident R79 was admitted to the facility on [DATE]. Review of Resident R79's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/16/25, indicated diagnoses of high blood pressure, End Stage Renal Disease (ESRD - an inability of the kidneys to filter the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of post-traumatic stress disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for one of five residents reviewed (Resident R153).Findings include: Review of the facility policy Trauma Informed Care last reviewed 10/1/25, indicated to guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. For trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization. Develop individualized care plans that address past trauma in collaboration with the residents and family, as appropriate. Review of the admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of job description, clinical record review, facility documents, and staff interviews it was determined that the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to the use of mechanical lifts for two of seven employees (Nurse Aide (NA) Employee E26 and E27). Findings include: Review of the facility's NA Job Description indicated the NA will ensure a safe environment. Staff uses appropriate lifting devices to ensure resident and staff safety. Review of the clinical record indicated Resident R55 was admitted to the facility on [DATE]. Review of Resident R55's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/6/26, indicated high blood pressure, depression, and Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior). Review of Resident R55's physician orders dated 2/3/26, indicated that Resident R55 was to be transferred with a Hoyer lift, assist of two, no ambulation. 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 documents, resident clinical records and staff interviews it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) for two of three residents (Resident R18, R104).Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the admission record indicated Resident R18 was admitted to the facility 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 facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that hospice documentation was maintained for two of four residents reviewed for hospice services (Resident R55 and R137). Findings include: Review of facility policy Special Needs dated 10/1/25, indicated the facility will ensure that residents receive proper treatment and care for the following special services: Hospice. All hospice services are provided under contractual arrangement. Complete details outlining the responsibilities of the facility and the hospice agency are contained in this agreement. A copy of this agreement is on file in the facility. Review of the clinical record indicated Resident R55 was admitted to the facility on [DATE]. Review of Resident R55's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/6/26, indicated high blood pressure, depression, and Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking…

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, resident interview, and staff interviews it was determined that the facility failed to make certain that equipment was in safe operating condition for one of three facility vehicles (vehicle one).Findings include: During an interview on [DATE], at 10:40 a.m. Resident R280 stated that one of the facility's vehicles used to transport residents to appointments, had an expired vehicle inspection sticker displayed. During an observation in the facility's parking lot on [DATE], at 2:58 p.m. facility vehicle number one was revealed to have an inspection sticker with an expiration date of [DATE]. During an interview on [DATE], at 8:33 a.m. Van Driver Employee E22 stated that the facility employs three Drivers who operate daily to provide transportation services for residents, and that three vehicles are used to complete these services. During an interview on [DATE], at 11:25 a.m. Van Driver Employee E23 confirmed that Vehicle number One had an expired inspection of [DATE]. During an interview on…

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

Based on review of facility policy, personnel files and staff interview it was determined that the facility failed to ensure that one of four sampled Nurse Aides (NA) received a minimum of 12 hours of in-service education per year (NA Employee E7).Findings include: Review of facility policy Staff Development Program dated 10/1/25, indicated the facility will provide staff development and education to employees. Certified Nursing Assistants/Aides receive at least 12 hours of in-service per year. All employees receive in-service on mandatory in-services annually, with competency assessment included in the program. Annual training will include, at a minimum: Infection Prevention and Control, Fire Prevention and Safety, Accident Prevention, Disaster Preparedness, Confidentiality, Resident Psychosocial Needs, Restorative Nursing, Resident Rights, Privacy Rights and Dignity, Abuse Prevention and Reporting, Nutrition and Hydration, Hazardous Materials, and Ethical Code of Conduct. Review of NA Employee E7's personnel file indicated a date of hire on 11/18/13. Review of facility nurse aide…

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

Based on a review of facility menu, observations, and resident and staff interviews, it was determined that the facility failed to serve attractive, and palatable food for the lunch meal served on 12/29/25.Findings include: Review of a Resident Representative concern dated 12/8/25, stated You can't eat the food. Review of facility menu indicated that on 12/29/25, at lunch the following was to be served:Turkey Pot PieHoney Glazed CarrotsFruited GelatinChoice of MilkBeverage of Choice During resident interviews conducted on 12/29/25 from 11:06 a.m. through 11:51 a.m. the following statements were made: Resident R1 stated that food is Unappetizing, its cold, not tasty, and added that she has been at the facility for two years, but that food Has been worse the past couple months. Resident R2 stated that the food Sucks, and it's always been shit. They don't flavor anything. Resident R3 described the food as Crappy, and every so often we get slop. Resident R4 stated that the Food is barely edible. Resident R5 described the food as Iffy. Resident R6 stated that Food some days is ok, but…

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 job descriptions, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper supervision was provided for residents at high risk for elopement as required, resulting in a resident elopement creating an immediate jeopardy situation.Findings include: The job description for the NHA specified the primary purpose of the job position is to manage the Facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. The job description for the Director of Nursing specified the primary purpose of the job position was to plan, organize, develop, and direct the overall operation of the nursing service department in accordance with current federal, state and local standards,…

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 financial documents, and interviews with vendor and staff, it was determined that the facility failed to pay bills in a timely manner.Findings include: Review of the Nursing Home Administrator's job description indicated the primary purpose of the nursing home administrator is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To ensure the highest degree of quality care is provided to residents at all times. Be responsible for all financial transactions. Review of facility document Amendment to Payment and Forbearance Agreement dated 8/29/25, indicated that the facility was placed on weekly payment plans to Staffing Agency Vendor. During an interview on 9/24/25, at 11:54 a.m. Staffing Agency Vendor Representative stated prior to the above agreement, the facility owed $3,829,128.60 for services provided. The Staffing Agency provided the facility with a suspension on 9/16/25 at 5:06 p.m. due to non-payment of services. Payment was received 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.

Based on review of facility documentation, and staff interview it was determined that the facility failed to employ a qualified social worker for approximately 388 residents for nine days (8/30/25, 8/31/25, 9/1/25, 9/2/25, 9/3/25, 9/4/25, 9/5/25, 9/6/25, and 9/7/25).Findings include: Review of the facility documentation (timecard) indicated that a new social worker (Employee E5) started at the facility on 8/6/25. Review of facility documentation indicated that the previous social worker's (Employee E6) last day was 8/29/25. Review of the new social worker personnel file resume indicated a Bachelor of Arts - but failed to include what the Bachelor of Arts was in or a degree in the personnel file. During an interview on 9/16/25, with Human Resource Employee E4 indicated that they spoke with Social Worker Employee E5 and they indicated their Bachelor of Arts is in social sciences which is similar to social work. Surveyor requested documentation showing what Bachelor of Arts was in. Review of facility documentation Social Worker Employee E5 university transcripts indicated a Bachelor 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 a review of facility documentation, cited deficiencies from previous surveys, review of plan of correction documentation, vendor interviews, and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. This has to potential to effect 358 of 358 residents. Findings include: Review of the facility policy, Quality Assurance/ Performance Improvement (QAPI) dated 10/1/24, indicated that the facility will conduct quality assurance/improvement and assessment committee meeting at least quarterly to identify areas of service that are non-complaint, or with potential for improvement. The facility will ensure that there is an effective, facility-wide performance improvement program to evaluate resident care and performance of the organization. The plan is reviewed regularly to ensure that policy, procedure and adherence to standards and regulations is attained and maintained. The facility will develop and implement plans for improvement to address deficiencies identified by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility documents, resident clinical records and staff interviews, it was determined that the facility failed to ensure a resident had the capacity to understand the terms of an admission notice agreement (important information for nursing facilities and their spouses) for two of five residents (Residents R2 and R3), and failed to ensure residents and resident representatives were given a choice regarding facilities in which to transfer a resident to for three of seven residents (Residents R6, R7, and R8).Findings include: Review of the facility admission notice packet indicated this information packet contains important information about your rights as a resident of a nursing facility, and information about Medical Assistance (MA), a program which can help pay for nursing facility care for people who cannot pay all of the cost of care by themselves. Federal law requires the nursing facility to give you this information. The four parts to this admission packet contain: Part…

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 ensure the resident representatives were appropriately notified of a decision to transfer residents from the facility for seven of nine residents reviewed (Residents R4, R5, R6, R7, R8, R9, and R10).Findings include: Review of facility policy Transfer and discharge date d 10/1/24, indicated the facility must notify the resident and, if known, the family member, surrogate, or representative of the transfer and the reasons for the transfer, and record the reasons in the clinical record. Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record indicated Resident R4 was admitted…

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, and failed to document a reason for transfer to an alternate health care provider for seven of seven residents sampled with facility-initiated transfers (Residents R4, R5, R6, R7, R8, R9, and R10).Findings include: Review of facility policy Transfer and discharge date d 10/1/24, indicated the facility must notify the resident and, if known, the family member, surrogate, or representative of the transfer and the reasons for the transfer, and record the reasons in the clinical record. Review of the clinical record indicated 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 9/17/25, indicated diagnoses of schizoaffective disorder (a mental disorder in which a person experiences a combination…

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 clinical records, and staff interview it was determined that the facility failed to provide reasonable accommodation of needs for two of 25 residents reviewed (Resident R2 and R3).Findings include:During an observation of resident rooms on the first floor on 10/29/25 Resident R2 and R3 bathroom had caution tape around the commode. During an interview on 10/29/25, at 11:00 a.m., Licensed Practical Nurse (LPN) Employee E3 stated that Resident R2 and R3's restroom has been inoperable for a few months. Employee E3 stated Resident R2 and R3 have to use the restroom on the other nursing unit Grove 2. During an interview on 10/29/25 at 1:00 p.m. Maintenance Employee E4 stated Resident R2 and R3 have not been able to use their commode for a month, and he hasn't looked at it in the past week.During an interview on 10/29/25, at 1:30 p.m., the Director of Nursing confirmed that the facility failed to offer Resident's R2 and R3 a room move and to provide reasonable accommodation of needs for two of 25 residents reviewed (Resident R2 and R3).28 Pa. Code 201.29…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of 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 one of five residents reviewed (Resident R1).Findings include:Review of facility policy Medication Administration dated 10/1/25, indicated medications are administered, as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so to comply with Federal Laws governing Medication Administration and in order to ensure the safe, accurate and timely administration of medications. The employee who administers medications to residents shall record and sign on the individual medication record of each resident the medication, dosage and time it was given. This shall be done as soon as possible after the medications have been given. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS - a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, facility documents, and staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of four residents reviewed (Resident R1). This was identified for past non-compliance for Resident R1.Finding include: Review of facility policy Abuse: Protection From Abuse dated 10/1/24, indicated the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Involuntary seclusion/restraint is defined as separation of a resident from other residents or from his/her room or confinement to his/her room (with or without roommates) against the resident's will, or the will of the resident's legal representative. The facility is a restraint free facility. The facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents,…

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 ensure that residents were free from physical restraints for one of four residents reviewed (Resident R1). This was identified for past non-compliance for Resident R1.Finding include: Review of facility policy Abuse: Protection From Abuse dated 10/1/24, indicated the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Involuntary seclusion/restraint is defined as separation of a resident from other residents or from his/her room or confinement to his/her room (with or without roommates) against the resident's will, or the will of the resident's legal representative. The facility is a restraint free facility. The facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants,…

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

Based on a review of facility policy, observation and staff interview, it was determined that the facility failed to properly maintain cleanliness and sanitation of the main kitchen and basement storage areas and failed to properly date and store food products in a manner to prevent foodborne illness in the main kitchen and basement storage areas. Based on a review of facility policy, observation and staff interview, it was determined that the facility failed to properly maintain cleanliness and sanitation of the main kitchen, basement storage areas, and failed to properly date and store food products in a manner to prevent foodborne illness.Review of the facility policy Sanitation last reviewed 10/1/24, indicated the food service area shall be maintained in a clean and sanitary manner. Review of the facility policy Food Storage last reviewed 10/1/24, indicated food storage area shall be maintained in a clean, safe, and sanitary manner. Food area shall be clean at all times. Un-served leftovers shall be labeled, dated and stored for a period not to exceed seven days. All food or…

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

Based on review of facility financial documents, interviews with vendor and staff, it was determined that the facility failed to pay bills in a timely manner.Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), dated 1/13/25, indicated that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are jeopardized. Review of the Nursing Home Administrator's job description indicated the primary purpose of the nursing home administrator is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To ensure the highest degree of quality care is provided to residents at all times. Be responsible for all financial transactions. During a review of Vendor 1's representative provided documentation on 8/5/25, at 8:45 a.m. revealed that there is an outstanding bill of approximately over $200,000…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the body soap needs for four of five residents (Residents R3, R4, R5, and R6).Findings include:Review of the facility policy Quality of Care: Attain and Maintain dated 10/1/24, indicated each resident must receive, and the facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.Review of the facility provided Safety Data Sheet (SDS - a standardized document that provides comprehensive information about the hazards of a chemical or hazardous substance and how to safely handle, store, and dispose of it) for Gentle Foam Soap dated 11/4/19, indicated recommended use as hand cleanser.Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE].Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/3/25, indicated diagnoses of high…

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 provide a clean, safe, comfortable, and homelike environment for ten of ten resident areas (One East, Two East, Three East, Grove One, Grove Three, Ramp to 2 West, Second Main, Third Main, Fourth Main, Fifth Main Floors and Two West). Findings include: Review of the facility policy Resident Environment dated 10/1/24, indicated the facility will provide an environment that is safe, clean, comfortable, and homelike, allowing the resident to use his or her personal belongings to the extent possible. Review of Title 42 Code of Federal Regulations §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation completed on 8/6/25, at 11:25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility assessment, employee education documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for five of five staff members (NA Employee E11, LPN Employee E18, NA Employee E21, NA Employee E22, and RN Employee E23).Findings include: Review of the facility assessment last reviewed July 2025, indicated:-[NAME] Rehabilitation and Wellness Center will maintain and adequately trained and competent staff. Mandatory education for [NAME] employees is provided in 3 ways. Mandatory education is delivered and tracked by the Director of education to ensure compliance with state and federal regulations.-Self-Directed Coursework - Employees will be given materials to review and will be required to complete a test. Topics covered in self-directed coursework include Compliance and Ethics, Quality Assurance and Performance Improvement (QAPI) process, Effective Communication, Dementia overview, ADL book…

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, observation and staff interview, it was determined that the facility failed to provide the right for privacy and dignity for two of five floors (Second and Fifth Main Floor). Findings include: Review of facility policy Resident Rights dated 10/1/24, indicated the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. During a tour of the Second Floor on 8/7/25, at 11:05 a.m. revealed the following: - Second main south men's restroom failed to have a curtain for one of two-bathroom stalls to maintain the resident's privacy. During an interview on 8/7/25, at 11:10 a.m. Registered Nurse (RN) Employee E8 stated, It should have one, and confirmed the above findings. During a tour of the Fifth Floor on 8/7/25, at 11:20 a.m. revealed the following: - Fifth main south patient's restroom failed to have an appropriate size curtain to maintain residents' privacy for the first bathroom stall.- Fifth main south patient's restroom failed to have a curtain on the fourth…

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 properly monitor weight and nutrition status by failing to obtain weights or act upon weight changes for two of five residents (Residents R13, and R14).Finding include:Review of the facility policy, Resident Weights last reviewed 10/1/24, indicated monthly weights will be obtained weekly times four weeks following admission/readmission and monthly thereafter. All weights will be transcribed in the resident's electronic record.Review of Resident R13's admission record indicated admission to the facility on 9/13/24.Review of Resident R13's Minimum Data Set (MDS-periodic assessment of care needs) assessment dated [DATE], included diagnoses of hypertension (high blood pressure), hyperlipidemia (high fat in the blood) and diabetes (high sugar in the blood) Review of Resident R13's current care plan dated 9/16/24, indicated Resident R13 is a nutrition risk monitor weight.Review of Resident…

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

Based on staff interviews it was determined that the facility failed to employ a qualified Registered Dietitian (RD) for two of twelve months (June 2025, and July 2025) as required. Findings include: Review of the facility policy Registered Dietician last reviewed 10/1/24, indicated the dining service department is under the guidance of a qualified dietician. The dietician is responsible for, but not limited to:. Assessing the nutritional needs of resident population Developing therapeutic diets Making diet recommendations consistent with meeting the nutritional needs of the resident population. Review of the Registered Dietician Job description indicated the primary purpose of the job position is to implement, coordinate and evaluate the medical nutrition therapy for the residents, provide resident and family education, provide nutritional assessment and consultation to assist in planning, organizing and directing the food and nutritional services of the facility During an interview completed on 8/5/25, at 12:00 p.m. upon asking Dietary Manager Employee E6 concerning the RD…

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

Based on a review of facility policies, documents, observations and staff interviews it was determined that the facility failed to properly approve the current menu cycle with the registered dietician (7/14/25, thru 8/10/25) as required which created the potential for conflicting guidance which may result in residents being provide inappropriate and inaccurate portion sizes and food product consistency for their prescribed therapeutic diet.Findings include: Review of the facility policy Registered Dietician last reviewed 10/1/24, indicated the dining service department is under the guidance of a qualified dietician. The dietician is responsible for, but not limited to:. Assessing the nutritional needs of resident population Developing therapeutic diets Making diet recommendations consistent with meeting the nutritional needs of the resident population. Review of the Registered Dietician Job description indicated the primary purpose of the job position is to implement, coordinate and evaluate the medical nutrition therapy for the residents, provide resident and family education,…

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 job descriptions, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper supervision was provided for residents at high risk for elopement as required, resulting in a resident elopement creating an immediate jeopardy situation.Findings include:Review of the policy Administrator dated 10/1/24, indicated the facility shall operate under the direction of a nursing home administrator (NHA) licensed by the Pennsylvania Board of Examiners for nursing home administrators. The licensed nursing home administrator will operate the facility consistent with laws, regulations, and standards of practice recognized in the field of health care administration.The job description for the NHA specified the primary purpose of the job position is to manage the Facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all…

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, resident and staff interview it was determined that the facility failed to protect resident property with the theft and loss of two residents personal items ( Resident R1 and Resident R2) and failed to replace Resident R1 and R2 property. Findings include: Review of facility policy Resident Personal Belongings/Inventory, Storage and Retrieval - upon DC or change in location notification dated 10/1/24, indicated: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident ' s medical symptoms. Residents' property includes all residents' possessions, regardless of their apparent value to others since they may hold intrinsic value to the resident. Residents are permitted to keep personal clothing and possessions for their use…

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 resident and staff interviews, it was determined that the facility failed to have an ample linen supply at the staff 's immediate disposal on four of ten units (2West, 3Main, 4Main, and 5Main). Findings include: Review of the facility policy Resident Rights dated 10/1/24, indicated all residents in the facility have rights guaranteed to them under Federal and State law, and by the facility's personnel. Review of the facility policy Flow of Care dated 10/1/24, indicated care will be provided to residents, as needed 24-hours a day to attain and maintain the highest level of functioning. Observation of the 2West linen cart on 4/18/25, at 9:26 a.m. indicated a small number of sheets and towels, and ten washcloths. The census on the unit was 49. Interview on 4/18/25, at 9:30 a.m. Nurse Aide (NA) Employee E1 confirmed the linen supplies were minimal and the staff run out frequently of wash cloths especially. We cut towels in half to wash faces. Interview on 4/18/25, at 9:35 a.m. NA Employee E2 indicated I had to go down to get linen…

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 and staff interviews, and observations of facility, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for nine of ten units (2East, 3East, 2West, 2Grove, 3 Grove, 5Main, 4Main, 3Main and 2Main). Findings include: During an observation on 4/18/25, at 9:06 a.m. Unit Manager (UM) Employee E8 was interacting with an unidentified resident on 2East unit (secure dementia care unit). During an interview on 4/18/25, at 9:07 a.m. UM Employee E8 confirmed that the census on 2East nursing unit was 49 and there were two aides on the floor Nurse Aide (NA) Employee E9 and NA Employee E10 and that staffing has not been great. During an observation on 4/18/25, at 9:10 a.m. Licensed Practical Nurse (LPN) Employee E11 was passing medications on the 3East nursing unit. During an interview on 4/18/25, at 9:11 a.m., LPN Employee E11 confirmed the census on the floor was 46 and that staffing has been…

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 interview with vendors and staff, it was determined that the facility failed to pay bills in a timely manner for services without which the residents' health, psychosocial well-being, and safety are impacted. Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations subsection 201.14(g), dated July 24, 1999, revealed that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are impacted. Review of Nursing Home Administrator (NHA) Job Description, signed 10/10/23, indicated that the NHA is responsible for all financial transactions. Review of a Resident Representative concern dated 3/25/25, stated They didn't pay the cable, so we don't have TV. Review of a Resident Representative concern dated 3/26/25, stated Residents now do not have TV. They've been told that it's not a necessity, but then what is a necessity? Review of Resident Representative concern dated 4/1/25, stated that Residents don't have…

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

Based on a review of facility policy, facility documents, medical record reviews, resident interviews, vendor interviews, and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for four and a half days (3/22/25, 3/23/25, 3/24/25, 3/25/25, and 3/26/25) out of 31 days in March 2025. Findings include: Review of facility policy Activity Recreation Programs dated 10/1/24, indicated the facility recreation programs are designed to meet the individual needs of each resident. Programming reflects the schedules, choices and right of residents within the facility. Review of a Resident Representative concern dated 3/25/25, stated They didn't pay the cable, so we don't have TV. Review of a Resident Representative concern dated 3/26/25, stated Residents now do not have TV. They've been told that it's not a necessity, but then what is a necessity? During an interview on 4/2/25, at 9:56 a.m. the Director of Nursing (DON) confirmed that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care by failing to obtain transportation to appointments for four of four residents (Residents R1, R2, R3, and R4). Findings include: Review of facility policy Special Needs dated 10/1/24, indicated for services not covered, a facility is required to assist the resident in securing any available resources to obtain the needed services. The facility shall assist the resident if necessary in arranging transportation to and from external service sites. Review of facility policy Resident Rights dated 10/1/24, indicated the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. 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…

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 obtain transportation to a radiology appointment for one of four residents (Resident R1). Findings include: Review of facility policy Special Needs dated 10/1/24, indicated for services not covered, a facility is required to assist the resident in securing any available resources to obtain the needed services. The facility shall assist the resident if necessary in arranging transportation to and from external service sites. Review of facility policy Resident Rights dated 10/1/24, indicated the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. 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 1/30/25, indicated diagnoses of high blood pressure,…

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

Based on observations and staff interview, it was determined that the facility failed to properly maintain sanitary conditions in the main kitchen which created the potential for cross contamination. Findings include: During an observation of the main designated kitchen on 2/10/25, at 9:05 a.m. the following was observed: -brown debris in ice machine (two) -brown, fuzzy debris on wall fans (three) During an interview on 2/10/25, at 9:30 a.m. Dietary Manager Employee E24 confirmed the debris in ice machines. Employee E24 could not confirm the last time they were cleaned. During an interview on 2/10/25, at 9:45 a.m., Dietary Manager Employee E24 confirmed that the facility failed to maintain sanitary conditions in the main kitchen which created the potential for food borne illness. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.6(c) Dietary services. 28 Pa. Code: 201.14(a) Responsibility of licensee.

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 effectively manage the facility to prevent the elopement of a resident (Resident R456), which created an immediate jeopardy situation for all 461 of 461 residents. Findings include: The job description for the Nursing Home Administrator dated 10/10/23, specified the primary purpose of the job is to manage the facility in accordance with current applicable, federal, state, and local standards, guidelines, and regulations the govern long-term care facilities. It is the NHA job to follow all facility policies and to ensure the highest degree of quality care is provided to the residents at all times. The job description for the Director of Nursing dated 3/22/21, specified it is the responsibility of the DON to organize, develop, and direct the overall operations of the Nursing Service Department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility.…

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

Based on review of facility documents, and staff interviews it was determined the facility failed to designate a physician to serve as medical director. Findings Include: Review of the facility's medical director contract dated 1/1/21, indicated Doctor of Osteopathic Medicine (DO), Employee E40 is the President and CEO of a group that is responsible for medical directorship services of the facility. Review of information submitted to the Department of Health, on 2/13/25, at 1:30 p.m. revealed Medical Director, Employee E38 was the designated Medical Director of the facility since 9/1/16. Review of the facility's emergency preparedness plan on 2/13/25, at 1:32 p.m. revealed DO, Employee E40 was the Medical Director. During an interview on 2/13/25, at 1:41 p.m. the Nursing Home Administrator (NHA) indicated Medical Director, Employee E38 has not been the Medical Director since he's been here. It was indicated Medical Director, Employee E38 was the medical director before 2023, and Medical Director, Employee E39 took over the beginning of 2024. NHA stated when Medicare/Medicaid…

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

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 ensure that care was provided in a manner which maintained resident dignity for two of six residents (Residents R149 and R169) and the facility failed to provide the right to a dignified dining experience for two of two lunches observed. Findings include: Review of facility policy Resident Rights dated 10/1/24, indicated the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Review of the clinical record indicated Resident R149 was admitted to the facility on [DATE]. Review of Resident R149's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/2/25, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and dementia (a group of symptoms that affects memory, thinking and interferes with daily…

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 council group interview, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for two of 12 nursing units (Four and Five Main Nursing Units.) Findings include: Review of the facility policy Resident Environment dated 10/1/24, indicated the facility will provide an environment that is safe, clean, comfortable, and homelike, allowing the resident to use his or her personal belongings to the extent possible. Review of Title 42 Code of Federal Regulations §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. During a resident council group interview on 2/12/25, at 11:01 a.m. two out of 11 residents voiced concerns with…

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

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 six of six residents sampled with facility-initiated transfers (Residents R39, R49, R73, R169, R460, and Closed Resident Record CR611). Findings include: Review of the clinical record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/30/25, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Resident R39's clinical record revealed that the resident was transferred to the hospital on [DATE]. Review of Resident R39's clinical record revealed no documented evidence that 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 observation, clinical record review and interview, the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice for three of six residents (Residents R42, R235 and R811). Findings include: Review of facility policy Oxygen Administration dated 10/1/24, indicated to change pre-filled humidification systems and tubing at least weekly. Review of the admission record indicated Resident R42 was admitted to the facility on [DATE]. Review of Resident R42's Minimum Data Set (MDS - a periodic review of care needs) dated 11/16/24, indicated the diagnoses of high blood pressure, chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R42's physician orders dated 11/11/24, indicated change oxygen tubing, humidification bottle, and cleanse…

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 five of six residents (Residents R33, R51, R141, R168, and R296). Findings include: Review of facility policy Trauma Informed Care dated 10/1/24, indicated the facility will develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate and identify and decrease exposure to triggers that may re-traumatize the resident. Review of Resident R33's record indicated the resident was admitted on [DATE]. Diagnoses included major depressive disorder, opioid dependance and Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense…

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, as well as staff interviews, it was determined that the facility failed to ensure a physician completed the initial visit for three of three residents (Resident R116, R229, and R422). Findings include: Review of Resident R116's clinical record indicated admission to the facility on 6/6/24. Review of Resident R116's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/13/24, indicated diagnoses of dementia (occurs when the supply of blood to the brain is reduced or blocked completely, which prevents brain tissue from getting oxygen and nutrients.) hypertension (high blood pressure) and depression. Review of Resident R116's clinical record revealed a new patient visit was completed by Certified Registered Nurse Practitioner, Employee E35 on 6/7/24. The facility failed to ensure the resident's initial visit was conducted by a physician. Review of Resident R229's clinical record indicated admission to the facility on [DATE]. Review of Resident R229's MDS dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined the facility failed to provide a bed, a mattress and functional furniture in resident rooms on the [NAME] Wing for 17 out of 17 rooms (Third Floor). Findings include: Review of the facility policy Resident Environment dated 10/1/24, indicated the facility will provide an environment that is safe, clean, comfortable, and homelike, allowing the resident to use his or her personal belongings to the extent possible. §483.90(e)(2) -The facility must provide each resident with-- (i) A separate bed of proper size and height for the safety and convenience of the resident; (ii) A clean, comfortable mattress; (iii) Bedding, appropriate to the weather and climate; and (iv) Functional furniture appropriate to the resident's needs, and individual closet space in the resident's bedroom with clothes racks and shelves accessible to the resident. During an observation on 4/10/25, at 1:00 p.m., of the [NAME] Wing 3rd floor revealed: - room [ROOM NUMBER] (dual occupancy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations and staff interview, it was determined that that the facility failed to determine it was safe to self-administer medications for two of six residents (Resident R811 and R812). Findings include: Review of the facility policy Self-Administration of Medications dated 10/1/24, indicated residents have the right to self-administer medications if ordered by the physician, and the resident is competent to safely self-administer the medications as determined by the interdisciplinary team. Review of the clinical record revealed that Resident R811 was admitted to the facility on [DATE]. Review of Resident 811's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/5/25, indicated diagnoses of alcoholic cardiomyopathy (the heart is unable to pump blood efficiently, leading to heart failure from prolonged alcohol consumption), sarcoidosis of lung (autoimmune disease where the immune system starts attacking the body, forming small inflammatory lumps called…

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

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of 12 medication carts (Grove One- Back Medication Cart). Findings include: Review of facility policy Health Insurance Portability and Accounting Act (HIPAA) of 1996 dated 10/1/24, indicated the facility will keep information regarding a resident's health private and confidential. Do not allow any papers, documents, or any other format with resident information unattended. During an observation on 2/12/25, at 9:17 a.m. the Grove One Back Medication Cart at the nurses station was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. During an interview on 2/12/25, at 9:20 a.m. Registered Nurse Employee E10 confirmed the above observation. During an interview on 2/12/25, at 11:56 a.m. the Director of Nursing confirmed that the facility failed to maintain the confidentiality of residents' medical information as…

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 interview, observations of resident areas and nursing units, and staff interviews it was determined that the facility failed to make certain anonymous grievance forms are readily accessible for resident use and the facility failed to post the grievance procedure in prominent areas for two of 12 nursing units (Two East nursing unit and Three East nursing unit). Findings include: The facility Grievances/Concerns policy dated 10/1/24, indicated that the grievance/Complaint form will be submitted to the Grievance Official, who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility, maintaining confidentiality of all information associated with the grievance, issuing written grievance decisions to the resident, and coordinating with state and federal agencies as necessary. A copy of the grievance/complaint procedure is posted in prominent locations throughout the facility. During an interview on 2/11/25, at 9:46 a.m. Resident R7…

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 fully investigate an incident to eliminate possible abuse or neglect for one of three residents (Resident R456). Findings include: Review of the facility policy Incident and Accident Reports reviewed 10/1/24, indicated the facility will document all unusual occurrences and events. It was indicated an elopement requires an incident report to be completed. Review of the facility Abuse: Protection From Abuse reviewed 10/1/24, indicated an Accident or Incident Report Form must be completed for all reported accidents or incidents. An employee witnessing an accident or incident involving a resident, employee must report such occurrence to his or her immediate supervisor, as soon as practical. An investigation is implemented and witness statements are obtained. Review of Resident R456's admission record indicated he was admitted on [DATE]. It was indicated the resident was admitted to the locked…

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 records, admissions documentation and staff interview it was determined that the facility failed to provide a comprehensive review of resident admission rights and maintain admission documentation for one out of out three sampled records (Resident R247). Findings include: The facility Resident rights policy dated last reviewed 10/1/24, indicated the facility will protect and promote the rights of each resident, and informing the resident about what rights and responsibilities he or she has. Review of Resident R247's admission record indicated she was admitted on [DATE]. Review of Resident R247's diagnoses that included dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), and hypertension (a condition impacting blood circulation through the heart related to poor pressure). Review of Resident R247's transfer 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 a review of facility policy and the RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for six of 28 residents (Residents R296, R352, R381, R413, R458, and Closed Resident Record CR611). Findings include: Review of the facility policy Resident Assessment/Minimum Data Set dated 10/1/24, indicated the facility will conduct initially and periodically a comprehensive, accurate, and standardized reproducible assessment of each resident's functional capacity under the direction of a designated registered nurse. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of resident care needs), dated October 2024, indicated the following: - Section A2105: Discharge Status: This item documents the location to which the resident is being discharged at the time of discharge. Select the two-digit…

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, resident and staff interview it was determined that the facility failed to follow physician orders for wound care for two of four residents (Resident R436, and R812), failed to monitor a CGM (continuous glucose monitoring device), obtain physician orders for continuous monitoring of results, and failed to have a care plan for care and management of the device for one of three residents with special devices (Resident R213). Findings include: Review of the facility policy Wound Care dated 10/1/24, indicated the facility follows physician's orders to maintain the highest level of comfort and promote healing of wounds. Interview with the Director of Nursing on 2/13/25, at 2:00 p.m. indicated the facility did not have a policy for CGM. Review of the admission record indicated Resident R436 was admitted on [DATE]. Review of Resident R436's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/2/25, indicated the diagnoses of cellulitis (a bacterial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observation, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to prevent further decrease in range of motion for one of three residents (Resident R113). Findings include: Review of the facility policy Assistive Devices and Equipment dated 10/1/24, indicated the facility maintains and supervises the use of assistive devices and equipment for residents. Staff are trained and demonstrate competency on the use of devices and equipment prior to assisting or supervising residents. Review of the facility policy Pressure Ulcer Prevention dated 10/1/24, indicated residents will receive skin care, repositioning and nutritional support to assist in preventing the development of avoidable pressure ulcers. Pressure can come from shearing, friction, splints, casts, bandages, and wrinkles in the bed linen. Review of the admission record indicated R113 was admitted to the facility on [DATE]. Review of Resident R113's Minimum Data…

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 ensure that appropriate physician orders were obtained for residents with a supra-pubic catheter (a medical device that drains urine from the bladder directly through the abdominal wall), and failed to maintain catheter irrigation equipment for one of three residents (Resident R367). Findings include: Review of the facility policy Catheter Irrigation (flushing of the catheter and bladder with a sterile solution) dated 10/1/24, indicated the purpose is to cleanse and maintain a patent (open) catheter. Irrigate according to physician's order. Review of the clinical record indicated Resident R367 was admitted to the facility on [DATE]. Review of Resident R367's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/2/25, indicated diagnoses of neurogenic bladder (lack of bladder control due to a brain, spinal cord or nerve problem), paraplegia (paralysis of legs and lower body), and depression. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to obtain colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) care and management physician orders consistent with professional standards of practice for one of five residents reviewed (Resident R367). Findings include: Review of the Code of Federal Regulations (CFR) §483.25(f) Colostomy, urostomy, or ileostomy care. The facility must ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Review of the facility policy Colostomy Care dated 10/1/24, indicated the purpose is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter (stool). Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of three residents (Residents R379). Findings include: Review of Resident R379's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R379's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/4/24, indicated diagnoses of high blood pressure, cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain), and dysphagia (difficult swallowing). MDS section K-Swallowing/Nutritional Status K0520 indicated a feeding tube. Review of current physician order indicated Osmolite 1.2 (a type of feeding that will supply a person with nutrients and minerals) to be administered continual over 24 hours.…

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 policy and clinical records, staff and resident interview, it was determined that the facility failed to ensure that physician's orders were followed for the care of an IV Midline Catheter (a type of long-term intravenous catheter) for one of three residents reviewed (Resident R229 ). Findings include: Review of facility policy Intravenous access: Dressing Change dated 10/1/24, indicated the purpose is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened or soiled catheter site dressings. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled). Review of the admission record indicated Resident R229 was admitted to the facility on [DATE]. Review of Resident R229's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/5/25, indicated the diagnoses of seizure disorder (a person…

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 five dialysis residents (Residents R113, and R213). Findings include: Review of the facility policy Dialysis Care dated 10/1/24, indicated all residents receiving dialysis (a treatment for advanced kidney failure that filters wastes, salts, and fluid from your blood) therapy will be monitored and documentation will be maintained in the medical record. They will be assessed before and after dialysis treatment for compliance with their individualized plan of care. Review of the admission record indicated R113 was admitted to the facility on [DATE]. Review of Resident R113's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/22/25, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), anemia (the blood doesn't have enough healthy red blood cells), End Stage 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 facility policy, observations and staff interview it was determined that the facility failed to store medications and biologicals as required for two of 12 medication carts (1 Grove Back Medication Cart and 3 Main Medication Cart) and three of six medication rooms (2 Grove Medication Room, 2 Main Medication Room, and 5 Main Medication Room). Findings include: Review of facility policy Storage of Medications dated [DATE], indicated drug containers having soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels are relabeled before storing. Compartments containing medications are locked when not in use. Trays or carts used to transport such items are not left unattended. During an observation on [DATE], at 12:40 p.m. of the Third Main North Medication cart, three treatments were observed inside the medication cart that included: - One tube of Bengay (cream used for pain) - Tender Calm skin protectant (skin cream) - Zinc Oxide Ointment (used to protect skin) During an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documents and staff interviews, it was determined that the facility failed to provide dental services to meet the needs of residents for one of three residents reviewed (Residents R250). Findings include: Review of the facility Dental Services policy dated 10/1/24, indicated the facility will assist residents in obtaining routine dental care. This requirement makes the facility directly responsible for the dental care needs of the residents. Review of the clinical record revealed that Resident R250 was admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident R250's care plan dated 4/11/24, indicated the resident is at risk for altered dentition and/or mucus membrane related to obvious or likely cavity or broken natural teeth. It was indicated to obtain a dental consult as necessary. Review of Resident R250's physician order dated 10/7/24, indicated to consult the dentist for routine evaluation. Review of Resident R250's MDS (Minimum Data Set,…

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 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 clinical record revealed that Resident R811 was admitted to the facility on [DATE]. Review of Resident 811's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/5/25, indicated diagnoses of alcoholic cardiomyopathy (the heart is unable to pump blood efficiently, leading to heart failure from prolonged alcohol consumption), sarcoidosis of lung (autoimmune disease where the immune system starts attacking the body, forming small inflammatory lumps called granulomas), and depression. Review of Resident R811's Nursing admission evaluation dated 1/29/25, indicated Section H Cardiac/circulation - irregular rate. Section L Skin indicated chest - Life Vest. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement (A binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not.) for two of five residents (Residents R300, and R428). Findings include: Review of the admission record indicated Resident R300 was admitted to the facility on [DATE]. Review of Resident R300's Binding Arbitration Agreement indicated that the resident signed the document on 6/28/24. Review of Resident R300's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/4/24, indicated the diagnoses of Non-Alzheimer ' s Dementia (dementia caused by other diseases with symptoms forgetfulness, limited social skills, and impaired thinking abilities that interfere with daily functioning),…

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

Based on review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for two of four quarters (January 2024 through March 2024, and July 2024 through September 2024). Findings include: Review of facility policy Quality Assurance Performance Improvement (QAPI) dated 10/1/24, indicated that the facility will conduct quality assurance/improvement and assessment committee meeting at least quarterly to identify areas of service that are non-compliant, or with potential for improvement. Members include Administrator, Director Nursing, Physician, Pharmacy Consultant, three additional members that may include Nutrition. Environmental Services, Social Services, Activities, medical Records, Plant Operations, Human Resources, Rehabilitation. A review of the QAPI Committee meeting sign-in sheets from the period of January 2024 through March 2024, did not reveal that the Medical Director was in attendance. 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, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for one of five residents (Residents R367). Findings include: Review of the facility policy Enhanced Barrier Precautions dated 10/1/24, indicated enhanced barrier precautions (EBP) are in place for residents with an infection or colonization of a multi-drug-resistant organism (MDRO), wounds and/or indwelling medical devices. Gowns and gloves are to be on and used when providing high contact care with a resident who is in EBP. Review of the clinical record indicated Resident R367 was admitted to the facility on [DATE]. Review of Resident R367's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/2/25, indicated diagnoses of neurogenic bladder (lack of bladder control due to a brain, spinal cord or nerve problem), paraplegia (paralysis of legs and lower body), and depression. Review of Resident R367's physician order dated 1/29/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the Influenza and Pneumonia vaccine for two of six residents (Resident R101, and R133). Findings include: Review of facility policy Resident Immunizations dated 10/1/24, indicated that Pneumovax and influenza immunizations will be offered to residents. Purpose is to prevent transmission of pneumococcal pneumonia, influenza, and other agents as indicated. Pneumovax should be offered to all residents who have never received the vaccine, who have unknown status of vaccine, and those over age [AGE]. Influenza vaccine is offered September through April of each year. Review of the clinical record indicated Resident R101 was admitted to the facility on [DATE]. Review of Resident R101's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/9/24, indicated diagnoses of high blood pressure, anemia (too little iron in the body causing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the COVID-19 (a respiratory infection) vaccine for two of six residents (Resident R101, and R133). Findings include: Review of facility policy Covid Management Plan dated 10/1/24, indicated that residents and staff members will be offered the vaccine unless the immunization is medically contraindicated, or the resident or staff member has already been immunized. The resident or resident representative may refuse the vaccine, and may change their decision. Review of the clinical record indicated Resident R101 was admitted to the facility on [DATE]. Review of Resident R101's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/9/24, indicated diagnoses of high blood pressure, anemia (too little iron in the body causing fatigue), and arthritis. MDS section O0350-Covid 19 vaccination, is up to date was marked 0 indicating - no,…

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 and staff interviews it was determined that the facility failed to make certain that equipment was in safe operating condition for one of six residents (Resident R761). Findings include: Review of facility Resident Right policy dated 10/1/24, indicated that the facility will promote the exercise of rights for each resident. The nursing home shall establish and implement written policies and procedures setting forth the right of residents for the protection and preservation of dignity, individuality and, to the extent medically feasible, independence. Review of the clinical record indicated Resident R761 was admitted to the facility on [DATE]. Review of Resident R761's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/6/25, indicated diagnoses of high blood pressure, absence of right and left lower legs, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). MDS Section GG Functional Abilities admission RR1: Type 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 facility policy, observations and staff interview, it was determined that the facility failed to maintain an effective call system for one out of three resident restrooms in the East building (Two East Solarium/ common area restroom). Findings include: The facility Call lights policy dated 10/1/24, indicated that a call light system is used by this facility to respond to the resident's requests and needs. Be sure that the call light is plugged in at all times. During an observation on 2/10/25, at 9:38 a.m. of the Two East Solarium/ common area restroom door was observed open with no emergency call light or call cord attached for emergency use. During an observation on 2/12/25, at 9:33 a.m. of the Two East Solarium/ common area restroom door was observed open with no emergency call light or call cord attached for emergency use. During an interview on 2/12/25, at 9:35 a.m. the Licensed Practical Nurse (LPN) Supervisor Employee E7 indicated that failed to maintain an effective call system for one out of three resident restrooms in the East building as required. 28…

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, medical record review, resident interview, and staff interviews it was determined that the facility failed to ensure that meals were served at regularly scheduled times for one of five residents (Resident R1). Findings include: Review of facility policy Meal Service dated 10/1/24, indicated that meals are provided for resident to meet nutritional requirements and enhance the pleasure of eating. Record meal intake per facility policy. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 12/31/24, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), open foot wound, and malnutrition (lack of proper nutrition). Review of Resident R1's medical record revealed a physician's order dated 12/24/24, to provide a Consistent Carb (a steady amount of carbohydrates) diet. 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.

Based on observation, review of facility documents, and staff interview, it was determined that the facility failed to maintain a homelike environment for twelve of twelve units observed. (East Wing Second Floor, East Wing Third Floor, East Wing Fourth Floor, Grove First Floor, Grove Second Floor, Grove Third Floor, [NAME] Wing First Floor, [NAME] Wing Second Floor, Main Second Floor, Main Third Floor, Main Fourth Floor, and Main Fifth Floor). Findings Include: Review of the facility policy Resident Environment last reviewed 10/1/24, indicates the facility will provide an environment that is safe, clean, comfortable, and homelike. Review of the facility document Water Temperature Checks dated 12/10/24, indicated that water temperatures throughout the building were 94.3 - 98 degrees. During an interview on 12/11/24, at 11:02 a.m. Resident R2 stated that there is no hot water for showering. During an interview on 12/11/24, at 11:06 a.m. Resident R3 stated The water used to be hot, but it isn't hot anymore. During an interview on 12/11/24, at 11:14 a.m. Resident R 4 stated I 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.

Based on review of facility policy, clinical record review and staff interview, the facility failed to offer and assist residents the opportunity to vote for one of five residents (Resident R1). Findings include: Review of facility policy Resident Rights dated, 10/1/24, indicated All residents in this facility have rights guaranteed to them under Federal and State law, and by this facility' personnel. This facility will protect and promote the rights of each resident, including each of the following rights: Exercise his or her rights as a city (voting). Review of Resident R1 clinical record indicated resident was admitted in 5/15/24. Resident R1 clinical record progress notes dated 11/4/24, indicated Resident R1 expressed that she wanted to vote, Resident R1 asked about voting on 11/1/24. Resident R1 clinical record progress note dated 11/4/24, indicated, PT going around on unit telling other PT that you cannot vote, its not going to count. Your vote is not going to count. Your gonna take that lying down . See how there people contour and twist , they took my good given right to…

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

Based on review of facility policy, clinical record review and staff interview it was determined that the facility failed to provide individualized discharge planning for one of three residents reviewed (Resident R1). Findings include: Review of facility policy Transfer and Discharge dated 10/1/24, indicated There shall be a centralized coordinated discharge plan to ensure that the resident has a program of needed continuing care after discharge form the facility. Review of Resident R1 clinical record indicated resident was admitted in 5/15/24. Review of Resident R1 clinical record MDS (minimum data set - a periodic assessment of resident needs) dated 8/28/24, indicated diagnosis of anxiety disorder ( repeated episodes of sudden feelings of intense anxiety and fear or terror) , depression ( common and serious medical illness that negatively affects how you feel, the way you think and act), and on the admission sheet a diagnosis of other psychoactive substance abuse (uncontrolled use of a substance despite harmful consequences). Review of Resident R1 clinical record care plans…

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

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 ensure a resident received iron transfusions as ordered for one of six residents reviewed (Resident R1). Findings include: Review of facility policy Consultant Service Requirements dated 10/1/24, indicated the facility uses outside resources to furnish specific services provided by the facility. Review of facility policy Special Needs dated 10/1/24, indicated the facility will ensure that residents receive proper treatment and care. It was indicated for services not covered, a facility is required to assist the resident in securing any available resources [NAME] obtain the needed services. The facility has satisfactory arrangements to assist residents in obtaining emergency and routine care not offered at the facility on a regularly scheduled basis. The facility shall assist the resident if necessary…

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 documents, clinical record review and staff interview it was determined that he facility failed to assist and identify and meet residents highest practicable needs for one of three residents (Resident R1). Findings include: Review of facility job description social worker indicated Purpose of your job position - to ensure that the medically related emotional and social needs of residents are met/maintained on an individual basis. Review of Resident R1 clinical record indicated resident was admitted in 5/15/24. Review of Resident R1 clinical record MDS (minimum data set - a periodic assessment of resident needs) dated 8/28/24, indicated diagnosis of anxiety disorder ( repeated episodes of sudden feelings of intense anxiety and fear or terror) , depression ( common and serious medical illness that negatively affects how you feel, the way you think and act), and on the admission sheet a diagnosis of other psychoactive substance abuse (uncontrolled use of a substance despite harmful consequences). During an interview on 12/11/24, at 12:40 p.m. Director 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 facility policies, observations, and staff interviews, it was determined that the facility failed to maintain a sanitary environment for food preparation, and transport which created the potential for cross-contamination and food borne illness. Findings include: Review of the facility policy Sanitation last reviewed 10/1/24, indicated the food service area shall be maintained in a clean and sanitary manner . All utensils, counters, shelves and equipment shall be kept clean maintained in good repair be free from breaks, corrosions, open seams, cracks and chipped areas. Carts may be used to transport food to dining areas and soiled dishes back to the dining service department provided the compartment is sanitized between the transportation of soiled dishes and food. During an observation on 11/6/24, at 9:22 a.m. of the main kitchen dishwashing area the following was observed: · A cart containing nine clean coffee carafes with spilled coffee noted to surface of cart. · The coffee carafes noted to have dark brown/black staining noted to the insides. · A blackish film…

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, financial statements, resident and staff interview, it was determined that the facility failed to provide discharge notices that included evidence of reasonable and appropriate efforts to obtain payment for three out of 12 sample residents (Residents R7, R8, and Resident R11) Findings include: Review of Resident R7's clinical record indicates an admission date of 11/9/23. Review of Resident R7's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 8/2/24, indicated diagnosis of anemia (low iron in the blood), heart failure (the heart doesn't pump the way it should) and hypertension (high blood pressure). Review of Resident R7's financial statements dated 10/1/24, indicated a balance of $8,319.00. Review of Resident R7's records indicated a transfer/discharge notice dated 10/9/24 signed by the Nursing Home Administrator (NHA) due to non-payment. Review of Resident R7's business office notations indicated last…

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 have appropriate isolation signage posted for five of nine residents (Resident R1, R2, R3, R4, and R5). Review of the facility policy Infection Prevention and Control Program dated 10/1/24, indicated to maintain a consistent, comprehensive approach to the prevention and management of infections. The facility is committed to preventing adverse outcomes such as health care associated infections and their related events. Implementation of control measures and precautions basics such as cleaning and hand hygiene as well as standard and transmission-based precautions. The goals of the program are to: 1. Provide a safe and sanitary environment. 2. Decrease the risk of infection to residents and staff. 3. Monitor for occurrence of infection and implement appropriate control measures. 4. Identify and correct problems relating to infection control practices. 5. Facilitate compliance with state…

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 provide a clean, safe, comfortable, and homelike environment by maintaining an acceptable temperature range throughout resident areas for five of seven units on the same boiler line (Units 5 Main, 4 Main, 4 East, 3 East, and 2 East). Findings Include: Review of the facility policy Resident Environment last reviewed 10/1/24, indicates the facility will provide an environment that is safe, clean, comfortable, and homelike. Review of the facility policy Responding to Dangerous Temperature Levels dated 10/1/24, indicated heating, ventilation and air conditioning systems should be capable of maintaining an acceptable temperature range throughout resident areas. Review of Title 42 Code of Federal Regulations §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990, must maintain a temperature range of 71 to 81°F (Fahrenheit). Interview on 10/17/24, 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 observation, and staff interview, it was determined that the facility failed to maintain a clean homelike environment for nine of twelve units observed. (second floor main unit, third floor main unit, fourth floor main unit, fifth floor main unit, first floor west unit, second floor west unit, grove unit one, grove unit two and grove unit three). Findings Include: Review of the facility policy Resident Environment last reviewed 10/1/24, indicates the facility will provide an environment that is safe, clean, comfortable, and homelike. During an interview on 10/9/24, at 9:40 a.m. Maintenance Director Employee E6 stated we have gotten an automatic valve for the overflow boiler tank, I have also purchased steam traps, we have to shut the hot water off, we were waiting for a motor should be here next week, we want to do it all at once, hopefully next week, while its shut down the baffle's to the hot water will also be cleaned. We are fixing all these things hoping it would fix the issue. There is hot water,…

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 follow enhanced barrier precautions for six of twelve units (second floor main unit, third floor main unit, fourth floor main unit, fifth floor main unit, second floor west unit, and unit four east,) failed to provide a safe and sanitary environment to help prevent the potential for cross contamination in one of nine showers rooms (Main five shower room) and failed to properly maintain ice makers in a sanitary condition creating the potential for cross contamination in eight of twelve units. (second floor main unit, third floor main unit, fifth floor main unit, second floor west unit, unit four east, and unit grove one, unit grove two, and unit grove three). Findings include: Review of the facility policy Enhanced Barrier Precautions(EBP) last reviewed 10/1/24, indicated it is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention 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 interviews, it was determined that the facility failed to implement the written policies and procedures to ensure a complete and thorough investigation and timely reporting was completed for one of three residents (Residents R3). Findings include: Review of facility policy Abuse: Protection from Abuse last reviewed 10/1/24, indicated the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. The Facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse and neglect. The facility has a no tolerance stance on any staff taking or using photographs or recordings in any manner that would demean or humiliate a resident. -Training-Mandated staff training/orientation programs that include such topics as…

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

Based on review of clinical records and observations, as well as staff and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of three residents reviewed (Resident R5). Findings Include: Review of the facility's Flow of Care dated 10/1/23, indicated care will be provided to residents, as needed 24-hour a day to attain and maintain the highest level of functioning. Residents are to have baths/showers according to their care plan/schedule. Review of Resident R5's clinical record indicates admission to the facility on 5/13/24, with the diagnosis of pressure ulcer of right heel, diabetes (high sugar in the blood), and dependence on renal dialysis (treatment for people whose kidneys are failing). Review of Resident R5's bathing task weekly shower day indicate that resident is a weekly shower, further review revealed that from 9/1/24, thru 9/24/24, Resident R5 received one shower on 9/24/24. During an interview on 9/25/24, at 12:00 p.m. the Director of Nursing (DON) confirmed Resident R5's shower day is Sunday and…

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

Based on review of facility documents and staff interview, it was determined that the facility failed to provide access to medical records to a resident or representative within a 24 hour period and/or to provide copies of medical records to the resident or representative within 48 hours for four of fourteen residents (Resident CR (Closed Record)2, Resident CR3, Resident CR4, and Resident R5). Findings include: Review of facility documents indicated that a request for a copy of medical records by a representative of Resident CR2 was received on 8/7/24, and was never sent. Review of facility documents indicated that a request for a copy of medical records by a representative of Resident CR3 was received on 8/7/24, and was never sent. Review of facility documents indicated that a request for a copy of medical records by a representative of Resident CR4 was received on 8/20/24, and was never sent. Review of facility documents indicated that a request for a copy of medical records by a representative of Resident R5 was received on 8/23/24, and was never sent. During an interview 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 oberservations and staff interview, it was determined that that the facility failed to determine it was safe to self-administer medications for one of three residents (Resident R1). Findings include: Review of Resident R1's admission record indicated that she was admitted on [DATE], with diagosis that included cellulitis (bacterial infection that affects the deep layers of the skin and underlying tissue), anxiety disorder and major depressive disorder. Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment, periodic assessment of resident care needs) dated 8/9/24, indicated that the diagnoses remain current upon review. Review of Resident R1's physician orders dated 6/5/24, indicate wound dressing to right lower ankle. Nurses progress notes dated 6/15/24, 6/16/24, 6/28/24, 7/4/24, 7/10/24, 7/14/24, 7/22/23, 7/23/24, 7/28/24, 8/2/24, 8/16/24, 8/24/24, 8/26/24, 8/29/24 indicated R1 was performing her own dressing change and treatment supplies were kept in room. 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 clinical records and staff interview, it was determined that that the facility failed to revise care plans for two of three residents (Resident R1 & R2). Findings include: Review of Resident R1's admission record indicated that she was admitted on [DATE], with diagosis that included cellulitis (bacterial infection that affects the deep layers of the skin and underlying tissue), anxiety disorder and major depressive disorder. Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment, periodic assessment of resident care needs) dated 8/9/24, indicated that the diagnoses remain current upon review. Review of Resident R1's physician orders dated 6/5/24, indicate wound dressing to right lower ankle. Nurses progress notes dated 7/4/24, 7/10/24, 7/14/24, 7/22/23, 7/23/24, 8/2/24, 8/16/24, 8/24/24, 8/26/24, 8/29/24 indicated R1 was performing her own dressing change. Review of Resident R1's care plan failed to include interventions for self treatment of wounds. Review of Resident R2'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 clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision for two of three residents resulting in potential for resident accidents (Resident R1 & R2). Findings include: Review of Resident R1's admission record indicated that she was admitted on [DATE], with diagosis that included cellulitis (bacterial infection that affects the deep layers of the skin and underlying tissue), anxiety disorder and major depressive disorder. Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment, periodic assessment of resident care needs) dated 8/9/24, indicated that the diagnoses remain current upon review. Review of Resident R1's nurses progress notes dated 6/1/24, Resident R1 had a independent LOA yesterday (6/2/24). Reports bottle of benadryl ,Advil, weed gummies, 5 vape pens and bag of tobacco to roll with her roller, also, Resident R1 was visibly intoxicated. NA informed the nurse that resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to inform a resident's representative in advance of the proposed care, including the risk and benefits of the prescribed psychotropic medication for one out of seven sampled residents (Resident R1). Findings include: The Resident rights policy last reviewed 10/1/23, indicated that the nursing home shall establish and implement written policies and procedures setting forth the right of residents for the protection and preservation of dignity, individuality and, to the extent medically feasible, independence. Residents and their families or other representatives shall be fully informed and documentation shall be maintained in the resident's file to fully inform by a physician of his/her health and medical condition, and the facility shall give the resident and family the opportunity to participate in planning the resident's care and medical treatment. Review of Resident R1's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, interview with staff, it was determined that the facility failed to develop a comprehensive care plan to meet residents needs for one of four residents reviewed (Resident R3). Findings include: Review of Resident Assessment Instrument 3.0 User Manual effective October 2023, indicated that a Brief Interview Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15 cognitively intact 8-12 moderately impairment 0-7 severe impairment Review of Resident R2 Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 5/2/24, included diagnosis of dementia (impairment of brain function). Review of Section C. Cognitive Patterns, Questions C0500BIMS Summary Score revealed Resident R2 score to be 3. Review of Resident R3 admission record indicated he was admitted to the facility on [DATE]. Review of Resident R3 MDS dated [DATE], included diagnosis 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 clinical record, staff interviews it was determined that the facility failed to provide behavioral services for a behavioral need for one of four residents reviewed (Resident R3). Findings include: Review of Resident Assessment Instrument 3.0 User Manual effective October 2023, indicated that a Brief Interview Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15 cognitively intact 8-12 moderately impairment 0-7 severe impairment Review of Resident R3 admission record indicated he was admitted to the facility on [DATE]. Review of Resident R3 MDS dated [DATE], included diagnosis of Traumatic Brain Injury (acquired brain injury). Review of Section C. Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident 3 score to be a 12. Review of facility documentation submitted on 7/12/24, indicated the following: Resident R2 had her breast fondled by Resident R3: On 07/12/2024 while Employee…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documents, clinical record review, and staff interview, it was determined that the facility failed to provide necessary services and failed to make certain appropriate treatment and services for dementia were provided to one of four residents (Resident R2). Findings include: Review of facility policy Guidelines for Caregiver Interaction with Dementia dated 10/1/23, indicated: Guideline Statement: To ensure that Caregivers understand how to interact with residents living with Dementia and/or Cognitive Deficits. Staff will interact with residents in a manner that supports dignity and enhances residents abilities to successfully participate in life. Review of Resident Assessment Instrument 3.0 User Manual effective October 2023, indicated that a Brief Interview Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15 cognitively intact 8-12 moderately impairment 0-7 severe impairment Review of Resident…

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

Based on review of facility policy, pest control service invoices, pest sighting logs, observations, and staff interviews it was determined that the facility failed to maintain an effective pest control program for one out of five observed resident kitchenettes (2-East kitchenette). Findings include: The facility Pest control program policy dated 10/1/23, indicated that the resident has the right to a clean and homelike environment. The facility shall have processes in place to include a pest control program as identified by a contracted vended service. The facility will maintain an effective pest control program. Review of records of invoices from pest service provider dated July 2024, indicated that mouse traps were laid out; however, the record did not include evidence of efforts to eradicate mice on the 2-East nursing unit in July 2024. Review of Pest sighting log for May 2024, June 2024 and July 2024, indicated that rats and mice were observed in the nursing home on 5/21/24, 5/28/24, 6/10/24, 6/17/24, 6/24/24, and 7/4/24. During observations on 7/23/24, the 2-East Resident…

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

Based on a review of facility policy, observations, and staff interviews it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties in the Main Kitchen. Findings include: Review of facility policy Sanitation dated 10/1/23, indicated the food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. Kitchen waste that are not disposed of by mechanical means shall be kept in clean, leak-proof, nonabsorbent, tightly closed containers and shall be disposed of daily. Review of facility policy Nursing Care of the Diabetic Resident dated 10/1/23, indicated the facility will Offer snacks at bedtime for insulin dependent diabetics. During an observation of the Main Kitchen on 6/25/24, at 11:45 a.m. it was noted to be extremely dirty. During observations on the Two West, Three West, Grove One, Grove Two, and Grove Three units on 6/25/24, between 9:00 p.m. and 10:00 p.m., it…

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, facility observations, and resident and staff interviews, it was determined the facility failed to routinely offer evening snacks for insulin dependent residents on five of five nursing units (Two West, Three West, Grove One, Grove Two, and Grove Three nursing units). Findings include: Review of facility policy Nursing Care of the Diabetic Resident dated 10/1/23, indicated the facility will Offer snacks at bedtime for insulin dependent diabetics. Review of facility policy Sanitation dated 10/1/23, indicated the food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. Kitchen waste that are not disposed of by mechanical means shall be kept in clean, leak-proof, nonabsorbent, tightly closed containers and shall be disposed of daily. Review of facility policy Nursing Care of the Diabetic Resident dated 10/1/23, indicated the facility will Offer snacks at bedtime for insulin…

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

Based on review of the facility's admission agreement and staff interviews, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator. Findings include: Review of facility's admission Agreement packet, which contained the document Voluntary Arbitration Agreement indicated that Accordingly, any dispute arising out of relating to the provision of services by the Facility to the Resident, Resident's admission to the Facility, Resident's contracts with the Facility or the subject matter thereof, any breach of contract, including any dispute regarding the execution, validity or scope of this Arbitration Agreement or any of its clauses, will be resolved through arbitration administered by [name of arbitrator services company which the facility utilizes] and conducted pursuant to the [arbitrator] Rules of Procedure for Arbitration. The facility's arbitration agreement failed to provide for the selection of a neutral arbitrator agreed…

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 documents, clinical records, and staff interviews, it was determined that the facility failed to implement adequate safeguards to protect cognitively impaired residents in a secured memory unit from physical abuse for one of five residents (Resident R4). Findings include: Review of facility policy, Abuse: Protection From Abuse dated 10/1/23, indicated the resident has the right to be free from physical abuse and further defined physical abuse as including hitting, slapping, pinching, and kicking. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R4 was admitted to the facility initially on 12/4/23. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 5/15/24, included…

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 documents, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for two of three residents (Resident R2). Findings include: Review of the facility Medication Frequencies document, dated 8/2015, indicated that medications that are ordered at specific times must be given within one hour of the ordered time. During an interview on 7/2/24, at approximately 11:30 a.m., the Director of Nursing (DON) confirmed that the Medication Frequencies documents is still active. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the facility diagnosis list included history of traumatic brain injury, restlessness and agitation, and a seizure disorder. Review of a physician's order dated 6/23/24, indicated Resident R2 was to receive olanzapine (Zyprexa, an anti-psychotic medication) 2.5 mg (milligrams) Give 1 tablet by mouth every day and evening…

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, and staff interview, it was determined that the facility failed to maintain a clean homelike environment in one of three resident rooms observed (Resident R1) and failed to maintain a safe, comfortable, home-like environment for six of twelve units (second floor main unit, third floor main unit, fourth floor main unit, fifth floor main unit, east unit third floor and east unit fourth floor. Findings Include: Review of the facility policy Resident Environment dated 10/1/23, indicated the facility will provide an environment that is safe, clean, comfortable, and homelike. Observation 6/12/24, at 1:41 p.m. Resident R1 rooms baseboards appeared with grayish-brown streaks, scuff marks, the tile under sink was very worn and faded. The TV stand belonging to roommate was visible soiled with coffee ground like substance. During an interview 6/12/24, at 1:50 p.m. Licensed Practical Nurse (LPN) Employee E3 confirmed the baseboards appeared to have grayish brown like streaks and scuff marks, the tile…

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

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of a resident's medical information on one of three nursing units (Third Floor Main). Findings include: Review of the facility policy HIPAA- Health Insurance Portability and Accounting Act) last reviewed on 10/1/23, indicated that the facility will keep information regarding a resident's health private and confidential. This includes information on paper, faxed, on computer and spoken aloud. During an observation on 4/10/24, at 11:01 a.m. the Medication Cart on the Third Floor Main hallway floor was left unattended with the computer screen open with identifiable information, so that any passerby could see resident personal and confidential information. During an interview on 4/10/24, at 11:01 a.m. Infection Control Director Employee E3 confirmed that the facility failed to maintain resident identifiable personal and medical information in a confidential manner. 28 Pa. code: 211.5(b) Clinical records. 28 Pa. Code: 201.29(i) Resident Rights 28…

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. Findings include: A review of facility policy Sanitation dated 10/1/23, indicated the food service area shall be maintained in a clean and sanitary manner. All equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipper areas. During an observation on 2/26/24, at 9:30 a.m., of the walk-in cooler #3 in the main kitchen, conducted with Food Service Director (FSD) Employee E1, revealed that the cold air condenser fan covers and the ceiling immediately forward of these cooler fans had a build-up of dust, grime, and debris. FSD Employee E1 confirmed observation by surveyor when viewed. During an interview on 2/26/24, at 9:45 a.m., FSD Employee E1 confirmed that the facility failed to properly maintain kitchen equipment, walk-in cooler #3, in a sanitary condition…

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

Based on a review of facility policies, observations and staff interviews, it was determined that the facility failed to properly dispose of refuse, and failed to prevent the potential for rodent and insect infestation by maintaining a clean and sanitary outside refuse area. Findings include: A review of facility policy Sanitation dated 10/1/23, indicated the food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects. During an observation on 2/26/24, at 9:40 a.m., of the facilities refuse/dumpster area, conducted with Food Service Director (FSD) Employee E1, revealed that dock area aligned with the refuse dumpsters contained varied items of debris and garbage, and immediately in front of and besides/between the dumpsters on the ground, there were multiple plastic bags full of garbage with piles of debris scattered. FSD Employee E1 confirmed observation by surveyor when viewed. FSD Employee E1 confirmed that this…

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 job descriptions, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper supervision and assessments were provided for smoking residents as required, make certain that staff initiate Cardiopulmonary Resuscitation (CPR-an emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) in accordance with Pennsylvania Code Title 49 Professional and Vocational Standards as required, and make certain that staff assess, monitor, and follow physician orders after a resident fall, resulting in death as required which all resulted in three separate immediate jeopardy situations. Findings include: Review of the policy Administrator dated [DATE], indicated the facility shall operate under the direction of a nursing home…

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 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.18(e)(3), facility policy, and staff interviews, it was determined that the facility failed to meet with its governing body that is legally responsible for establishing and implementing policies regarding the management and operation of the facility as required. Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.18(e)(3), dated 7/1/23, indicated management must maintain ongoing relationship with the governing body, medical and nursing staff and other professional and supervisory staff through meetings and reports, occurring as often as necessary, but at least on a monthly basis. Review of the Adminstrator policy last reviewed 10/1/23, indicated the nursing home adminstrator is responsible for serving as a liason to the governing board. During an interview on 3/4/24, at 1:03 p.m. the Director of Nursing stated the facility does not routinely meet with the governing body. The DON confirmed the facility failed 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 staff interviews and a review of the facility's assessment and resident census and condition 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: §483.70(e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include: §483.70(e)(1) The facility's resident population, including, but not limited to, (i) Both the number of residents and the facility's resident…

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

Based on review of facility documents, and staff and resident interviews it was determined that the facility failed to ensure that residents received timely resolution to Resident Council concerns and provide evidence that the Resident Council invited facility administration staff to attend the meetings, and that there were multiple members of the facility administration present at each meeting for 13 of 13 Resident Council meetings (February 2023, to February 2024). Findings include: Review of Resident Council meeting minutes revealed no evidence that administration was invited to attend council meetings, council concerns were forwarded to the appropriate department, and resolutions to previous documented concerns were addressed and/or discussed with Resident Council members. - February 9, 2023 (14 residents/10 administration staff): staff talking on personal phones/using airbus; water temperatures; TV channels not working; lack of linens; poor condition of linens; labeling personal laundry; and facility cleanliness. Residents were told to file grievances, and that staff would be…

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 documentation, observations, grievance logs, council minutes, and staff, and resident interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for four of eight residents (R19, R211, R217, and R415). Findings include: Review of the facility policy Resident Environment dated 10/1/23, indicated the facility will provide an environment that is safe, clean, comfortable, and homelike. Resident R19's clinical record revealed an admission date of 10/02/19, with diagnoses including schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), Type 2 Diabetes (affects how the body uses glucose (sugar), pseudobulbar affect (episodes of sudden uncontrollable and inappropriate laughing or crying), low level personal hygiene, and high blood pressure. Observation on 2/27/24, at 10:13 a.m.…

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 facility investigative documents, and staff interviews, it was determined that the facility failed to ensure that residents were free from misappropriation (the act of stealing something that you have been trusted to care for and using it for yourself) of medications for four of four residents reviewed (Residents R11, R152, R251, and R418). Findings include: Review of facility policy Abuse: Protection from Abuse dated 10/1/23, indicated the resident has a right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Review of facility policy Controlled Medications dated 10/1/23, indicated medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special handling, storage, ordering, receipt, disposal, and recordkeeping requirements in the long-term care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for six of eight residents reviewed (Resident R65, R94, R96, R264, R345, and R209). Findings include: Review of the facility policy Oxygen Administration, last reviewed on 10/1/23, indicated oxygen therapy will be provided when a resident needs oxygen at a concentration greater than room air to treat hypoxia, and decreased pulmonary and myocardial work. Oxygen therapy will be ordered as appropriate using one of the following delivery systems: - Manual resuscitator. - Nasal Canula. - Simple mask. - Non-rebreathing mask. - Aerosol mask, tracheostomy collar, or T-tube. Procedure including but not limited to changing complete oxygen systems including humidification bottle, tubing, neb equipment and bad at least weekly and label with date. Review of the facility policy Cleaning and Disinfecting of BIPAP/CPAP Equipment (machines that use air pressure…

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, clinical record review, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of six of ten residents (Resident R280, R330, R318, R129, R406, R2). Findings Include: Review of the facility policy Flow of Care dated 10/1/23, stated care will be provided to residents, as needed 24-hours a day to attain and maintain the highest level of functioning. Review of the facility policy Supervision of Resident Nutrition dated 10/1/23, indicated each resident shall receive proper nutrition in accordance with the resident's assessment, care plan, and physician orders. It was indicated residents needing assistance in eating must be promptly assisted upon being served. Review of Nursing Assistant (NA) job description indicated NA's are responsible for assisting residents with preparing for meals, serve food trays, assist with feeding as indicated, and assist…

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, documents, and clinical records and staff interviews it was determined that the facility failed to provide evidence that resident's medications were reviewed monthly for irregularities for four of five residents reviewed (Residents R46, R54, R251, R280). Findings include: A facility policy entitled, Pharmacy Services dated 10/01/23, stated that a licensed pharmacist will review the drug regimen of each resident at least once a month and that the pharmacist will report any irregularities to the attending physician and the director of nursing. Resident R46's clinical record revealed an admission date of 1/06/23, with diagnoses including chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems), irregular heartbeat, dementia, and heart failure, and lacked evidence that a review of his/her medications was conducted monthly by a licensed pharmacist. Resident R54's clinical record revealed an admission date of 7/21/22, with diagnoses including schizophrenia (serious mental illness that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policies, clinical record review and staff interviews, it was determined that the facility failed to ensure a resident's right to be informed of their total health status and participate in treatment decisions for one out of three sampled (Resident R468). Findings include: Review of the facility admission and Referral Process policy last reviewed 10/1/23, indicated the admission Department is responsible for coordinating all information and referral requests. The admission date and time will be arranged and the Responsible Party/ Resident will complete all required documentation. Review of the facility Resident Rights policy last reviewed 10/1/23, indicated all residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility will promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, observation, resident, and staff interview, it was determined that the facility failed to accommodate appropriate adaptive equipment to attain and maintain the highest level of functioning for hygiene needs of one of five residents interviewed (Resident R415). Findings include: Review of facility policy Flow of Care dated 10/1/23, indicated care will be provided to residents, as needed 24-hours a day to attain and maintain the highest level of functioning. Any concerns are to be addressed by the charge nurse responsible for that resident. Review of the admission record indicated Resident R415 admitted to the facility on [DATE]. Review of Resident R415's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/20/24, indicated the diagnoses seizure disorder (a person experiences abnormal behavior, symptoms, and sensations, sometimes including loss of consciousness), traumatic brain injury (TBI- brain dysfunction caused by an outside force, usually 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 and clinical record review and staff interview, it was determined the facility failed to notify the physician of a change in condition for two of four residents (Resident R21 and R101). Findings include: Review of the facility policy Notification of Condition Change: Physician dated 10/1/23, indicated a change in a resident's condition will be reported to the physician in a timely manner. Licensed professional nurses are responsible to provide timely and complete communication to physician when there is a change in resident's condition. Review of the facility policy Nursing Care of the Diabetic Resident dated 10/1/23, indicated obtain physician orders finger stick blood sugar testing including parameters for intervention. Document notification to physician of unstable and/or significant variances from baseline. Review of the facility policy Hypoglycemia Protocol dated 10/1/23, indicated low blood glucose less than 70 or physician ordered low parameter. -Hold all diabetic medications.…

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, facility documents, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain residents were free from abuse and neglect for two of eight residents (Resident R284 and R403). Findings include: Review of facility policy Abuse: Protection from Abuse dated 10/1/23, indicated the resident has a right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Abuse includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. Review of the facility policy Flow of Care dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for one of eight incidents reviewed (Resident R384). Findings include: Review of facility policy Abuse: Protection from Abuse dated 10/1/23, indicated the Facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse and neglect. Review of the admission record indicated Resident R384 was admitted to the facility on [DATE]. Review of Resident R384's MDS dated [DATE], indicated the diagnoses of high blood pressure, diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs). Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the administrator of the facility and to other officials for one of eight residents. (Resident R384). Findings include: Review of the facility policy Abuse Reporting and Investigation dated 10/1/23, indicated all reports of alleged or suspected abuse must be reported to the Administrator immediately. -The Department of Health will be notified of the alleged event by the Administrator or designee via the Electronic Event Reporting System per regulation. Additional notification to the Area Agency on Aging (Protective Services) and local authorities will be completed as appropriate based on the allegation. Review of the admission record indicated Resident R384 was admitted to the facility on [DATE].…

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 a potential allegation of abuse/neglect for a resident burn for one of eight residents (Resident R384). Findings include: Review of the facility policy Abuse Reporting and Investigation dated 10/1/23, indicated all reports of alleged or suspected abuse must be reported to the Administrator immediately. Identification of occurrences and patterns of potential mistreatment/abuse. Investigation - timely and thorough investigations of all reports and allegations of abuse. Review of the admission record indicated Resident R384 was admitted to the facility on [DATE]. Review of Resident R384's MDS dated [DATE], indicated the diagnoses of high blood pressure, diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow 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, 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 56 residents (Residents R124 and R383). Findings include: A facility policy entitled, Bed Hold Policy and Procedure dated 10/01/23, stated: that upon discharge from the facility and admission to a hospital, the Social Services department or designee will contact, by telephone and in writing, the resident/agent to inform them that the resident was discharged to the hospital and of the 15-day bed hold, and that a call will inform the family to expect the bed hold letter within the next few days, and that the bed hold letter and bed hold reservation will be mailed on the date of discharge to the hospital for all residents, regardless of payor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of The Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual Effective October 1, 2023, clinical records, and staff interviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS-periodic assessment of resident care needs) for two of 56 residents reviewed (Resident R280 and R383). Findings include: RAI coding instructions for Section P0100 (Restraints) indicated: identify all physical restraints that were used at any time (day or night) during the 7-day lookback period and to code 1 (used less than daily) if the item met the definition and was used less than daily during the observation period. RAI coding instructions for Section N0450 (Antipsychotic Medication Review) indicated: Did the resident receive antipsychotic medications since admission/entry or reentry or the prior assessment, whichever is more recent? Review of Resident 280's clinical record indicated the resident was admitted to 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 a review of facility policy, resident clinical record review, and staff interview, it was determined the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for two of 28 residents (Resident R227, and R384). Findings include: Review of the facility policy MDS/RAI/Care Planning last reviewed 10/1/23, indicate to develop a written plan of care individualized for each resident, which identifies through an assessment process his/her strength, problems and needs. Review of the facility policy Side Rails Proper Use last reviewed 10/1/23, indicate the use of quarter or half-side rails, as an assistive device will be addressed in the resident care plan. Review of Resident R227's clinical record indicates an admission date of 3/7/23, with diagnosis of hypertension (high blood pressure), cerebrovascular accident (loss of blood flow to the brain), hemiplegia (one sided weakness or paralysis). Review of Resident R227's physician orders 1/19/24,…

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

Based on review of resident 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 one of five residents with a urinary catheter (Resident R431). Findings include: Review of the facility policy Catheter Care last reviewed 10/1/23, indicate ensure drainage bag is covered for privacy. Review of the facility policy Catheter Insertion Procedure last reviewed 10/1/23, equipment: indicate the appropriate size and type of catheter. Review of the facility policy MDS/RAI/Care Planning last reviewed 10/1/23, indicate to develop a written plan of care individualized for each resident, which identifies through an assessment process his/her strength, problems and needs. Review of resident R431's Minimum Data Set (MDS - periodic assessment of care needs) indicated reentry to facility on 12/29/23, diagnosis of anemia (low iron in blood), pressure ulcer sacral area (bottom of spine) stage four (deep wound that impacts muscle, tendon, and bone).Section H indicated indwelling catheter.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop an individualized care plan to address the resident's specific nutritional concerns and preferences for one of four (Resident R108) records reviewed. Findings include: Review of facility policy MDS/RAI/Care Planning, dated 10/1/23, indicated that residents will have a comprehensive assessment completed by day 14 of stay and a comprehensive care plan completed and reviewed within 7 days of the completion date of the MDS (Minimum Data Set assessment - a mandated assessment of a resident's abilities and care needs). The resident will then be assessed at least quarterly and care plan reviewed by the interdisciplinary team according to OBRA scheduled and more often if required for Medicare reimbursement. Policy further indicated that the facility will develop a written plan of care individualized for each resident, which identifies through an assessment process his/her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined that the facility failed to ensure a resident with dementia receives the appropriate treatment and services to attain or maintain his highest practicable physical, mental, and psychosocial well-being for one of four residents reviewed (Resident R280). Findings include: Review of the facility Guidelines for Caregiver Interaction with Dementia policy last reviewed 10/1/23, stated staff must change their thinking from trying to control behavior to understanding and changing the reason behind the behavior. Review of the facility Antipsychotic Drugs policy last reviewed 10/1/23, indicated antipsychotic drugs should not be used unless medical causes such as pain, constipation, fever, or infection have been ruled out. Review of Resident 280's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses that included psychotic disorder (severe mental health disorders that cause abnormal thinking 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 a review of facility policy, clinical records and staff interviews, it was determined that the facility failed to limit as needed antipsychotic drugs to 14 days for one of four residents (Resident 280). Findings include: Review of the facility Antipsychotic Drugs policy last reviewed 10/1/23, indicated antipsychotic drugs should not be used unless medical causes such as pain, constipation, fever, or infection have been ruled out. Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in effort to discontinue these drugs. As needed (PRN) antipsychotics must have a 14 day limit. Orders may not extend beyond 14 day limit. Review of Resident 280's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses that included psychotic disorder (severe mental health disorders that cause abnormal thinking and perceptions), anxiety, and non-Alzheimer's dementia (loss of memory and other intellectual…

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 facility tour, review of facility policies, staff interviews, and review of Centers for Disease Control (CDC) guidelines, it was determined that the facility failed to maintain infection control practices to prevent the potential for contamination for one of three resident wounds (Resident R101), and one of two photocopy/mail room (Administration hallway). Findings include: Review of facility policy Infection Control Plan, Program and Committee dated 10/1/23, indicated a comprehensive process that addresses detection, prevention, and control of infections. The facility is committed to preventing adverse outcomes such as health care associated infections and their related events, improving resident care by supporting staff in all areas of the facility, minimizing occupational hazards associated with the delivery of healthcare, and fostering evidence-based decision making. Review of admission record indicated Resident R101 was admitted to the facility on [DATE]. Review of Resident R101's MDS dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to maintain a clean, homelike environment on six of ten nursing units (2 East, 3 East, 4 East, 2 Main, 4 Main, and 5 Main Nursing Units). Findings include: Review of the facility policy Housekeeping Administration dated xxx, indicated the facility will assure the clean and sanitary condition of the facility to provide a safe and hygienic environment for residents and staff. During observations on 11/28/23, from 9:35 a.m., through 11:15 a.m., the following was identified: The 2 East Nursing Unit: Residents R1, R2, and R3 had soiled floor and no can liner in trash can. Residents R4, R5, and R6 had soiled floor, urine odor emitting from room, and bathroom floor was soiled. Residents R7, R8, R9, and R10 had a broken air conditioning unit that needed repair. Residents R11, R12, and R13 had broken, leaking air conditioner unit, saturated towels were in place under unit, the floor by the…

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

Based on observations, review of the Activity Calendars for two months and staff interview, it was determined that the facility failed to provide an ongoing program of activites to meet based on the designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. Findings include: During a review of Activities Calendar for November 28, 2023, the calendar indicated National French Toast Day starting at 10 a.m. During observations of the East, Grove, West, and Main Nursing Units from 10:00 a.m. through 11:12 a.m., there were no Activites being done in any areas. A form taped on each units wall indicated that the Activity identied would not start until 2:00 p.m. The calendars indicated no Activites held on Saturdays and Sunday only indicated Church. During observations of residents on each Nursing unit identified residents ambulating throughout the units and sitting at the nurses station. The 2 East dementia unit residents were all sitting at the nurses station and staff…

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

Based on review of the facility policy, review of the Activity Director's personnel file and staff interviews, it was determined that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program. The findings include: Review of The Activities Director Job Description last reviewed on 10/1/23, indicated that she/he is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program designed to meet the social, psychosocial and therapeutic needs of the resident. The programs are to be in accordance with current federal, state and local standards. This includes the completion and/or directing/delegating the completion of the activities component of the comprehensive assessment; and contributing to and/or directing/delegating the contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident in compliance with Federal and State regulations. Review of the Acting Activity…

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

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label and date food products and maintain the ice machine which created the potential for cross contamination in two of three nursing unit kitchenettes (Four Main and Five Main nursing units). Findings include: Review of the facility policy Food Storage dated 10/1/23, indicated that food storage areas are to be clean, food stored in refrigerators will be dated, and that an accurate thermometer will be in each refrigerator. Review of the facility policy Ice Machines and Ice Storage dated 10/1/23, indicated that ice-making machines can become contaminated by colonization of microorganisms. During an observation of the Four Main Kitchenette on 11/28/23, beginning at approximately 9:30 am the following was observed: -One undated frozen entrée, with a resident's name. -Grocery store bag full of loose popsicles with no name. -Open, undated container of sherbet with no name. -Frozen bottle of Gatorade with no name. -Container of prune juice, with an expiration…

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

Based on observation and staff interview, it was determined that the facility failed to maintain an effective call system for two of four communal resident restrooms (Five Main South and Five Main North communal restrooms). Findings include: During an observation on 11/28/23, at 10:07 a.m. of the Five Main South communal restroom revealed that the call light cords for the individual commodes were wrapped so tightly around the hand rails they were unable to be alarmed. During an observation on 11/28/23, at 10:16 a.m. of the Five Main North communal restroom revealed that the call light cords for the individual commodes were wrapped so tightly around the hand rails they were unable to be alarmed. During an interview and observation on 11/28/23, at 10:20 a.m. Nurse Aide Employee E6 confirmed that the call lights were unable to be alarmed when wrapped tightly around the handrail. During interview on 11/28/23, at approximately 3:45 p.m. Nursing Home Administrator confirmed that the facility failed to maintain an effective call system for two of four communal resident restrooms. 28 Pa…

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

Based on review of facility policy, observation. and staff interviews, it was determined that the facility failed to maintain an effective preventative maintenance program in order to keep mechanical lift slings in safe operating condition for one of four mechanical lifts reviewed (Four Main North Unit mechanical lift). Findings include: Review of the facility policy, Maintenance Administration dated 10/1/23, indicated the maintenance department will maintain documentation to evidence preventive safety measures are implemented. During an observation on 11/28/23, at 9:47 a.m. a mechanical lift on the Four Main nursing unit was observed to have a missing electrical cover plate for the scale located on the top of the lift arm. The missing cover plate allowed wires to be visible and accessible for the scale. During an interview on 11/28/23, at 9:50 a.m. the Four Main Unit Manager Employee E5 confirmed she had not been notified that the scale required maintenance. During an interview on 11/28/23, at 10:16 a.m. Maintenance Director Employee E3 confirmed that there was not a preventive…

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

Based on review of facility policy, clinical records, resident interviews and observations, and staff interviews, it was determined that the facility failed to determine it was safe to self-administer medications for eight of 31 residents (R18, R19, R4, R9, R10, R20, R17, and R21). Findings include: Review of the facility policy, Medication Administration dated 10/1/23, indicated residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. The policy further stated that medications are administered at the time they are prepared. Preparation of doses for more than one scheduled administration time shall not be permitted. During an observation on 10/18/23, at 10:03 a.m. Resident R18 had a medication cup on his bedside table. The cup had the first name of Resident R19 on it. Resident R18 and R19 are roommates, with beds across from each other. Review of Resident R18's plan of care updated 5/16/23, failed to include a care plan for self-administration of medications.…

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 observations and staff interviews is was determined that the facility failed to make certain that out-of-date medications were disposed of for two of four nursing units (Three Main and Four Main). Findings include: Review of the facility policy Housekeeping Administration dated 10/1/23, indicated the housekeeping supervisor will be responsible for assuring the clean and sanitary condition of the facility to provide a safe and hygienic environment for residents. During an observation on 10/18/23, at from 10:03 a.m. through 10:33 a.m. of the Three Main nursing unit, the following was observed: 10:03 a.m.: Resident R2 had clothes piled in a bag on the floor; Resident R3 had clothes in bags on top of the dresser. The room floor was dirty, and fruit flies were present in the room. 10:05 a.m.: Resident R3 had clothes piled on the floor. The room floor was extremely dirty, fruit flies were present in the room, hangers and clothes were hanging suspended from the over-bed lights in the room. 10:12 a.m.: Resident R4 had clothes piled on the floor. 10:13 a.m.: Resident R5's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record reviews, resident interview and observations, and staff interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for nine of 31 residents (Resident R11, R22, R23, R24, R25, R26, R27, R28, and R29). Findings Include: Review of the facility policy Flow of Care dated 10/1/23, indicated that care will be provided to residents as needed to attain and maintain the highest level of functioning, that the provision of targeted care needs shall be documented on the point of care records, and that residents are to have two baths/showers/week unless the resident states otherwise. Review of Resident R22's admission record indicated he was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 9/12/23, included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and diabetes (a metabolic disorder…

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 observations and staff interviews is was determined that the facility failed to make certain that out-of-date medications were disposed of for two of four medication carts (Three Main North cart and Three Main South cart). Findings include: Review of the facility policy Storage of Medications dated 10/1/23, indicated: -No discontinued, outdated, or deteriorated medications are available for use in the facility. All such medication are destroyed. -Multi-dose vials or medications are dated upon opening or first use. Review of the United Stated Food and Drug Administration (U.S. FDA) approved prescribing information for Humulin N ( a type of insulin, an injectable medication used to treat diabetes ) dated 11/2018, indicated that in-use vials of Humulin N must be discarded after 31 days, even if the vial still has insulin in it. Review of the U.S. FDA approved prescribing information for the Basaglar Kwik-pen (a type of insulin in a pre-filled injection) dated 12/2015, indicated that in-use Kwik-pens must be used within 28 days. Review of the U.S. FDA approved…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of four residents with pressure ulcers. (Resident R1) Review of the facility policy Documentation dated 9/30/22, indicated nursing documentation will be concise, clear, pertinent, and accurate. Review of the facility policy Weekly Wound Documentation 9/30/22, indicated weekly wound documentation will be maintained to monitor the development, healing and progress of wounds. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses that included dementia, and mood disturbances. Review of the Minimum Data Set (MDS-periodic assessment of care needs) dated 10/10/23, indicated the diagnoses remain current. Review of a nurse note dated 8/21/23, indicated that Resident R1 had a new wound found on the left outer ankle measuring 1.5 cm (centimeters)…

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

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to have infection prevention and control policies that were current and based on national standards, and implement appropriate infection control precautions for two of three units (2 East and 3 East). Findings include: Review of the facility Hand Hygiene/Handwashing policy dated 9/29/22, indicated staff will perform proper hand hygiene procedures to reduce the incidence of infections. It was indicated handwashing and hand rubbing must be performed prior to having direct contact with patients. The policy stated gloves do not eliminate the need for hand hygiene. Review of the facility Isolation Procedure: Resident Placement in Transmission Based Precautions policy dated 9/29/22, stated transmission based precautions (Airborne, Contact, Droplet) must be implemented when indicated by suspicion or presence of infectious disease. Precautions must be initiated as indicated or ordered. Review of the facility COVID Management Plan policy dated 2/1/23, indicated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, COVID-19 line listing of positive residents, clinical record, and staff interview it was determined that the facility failed to notify families of residents with positive COVID-19 test results in a timely manner for two of five COVID-19 positive residents (Residents R3 and R4.) Findings include: Review of the facility's Notification of Resident's Responsible Party/Guardian policy dated 9/29/22, indicated the legal responsible party or guardian is to be notified of changes in condition or occurrences and documentation of notification must be recorded in the resident's clinical record. If official notification has not occurred by the end of a shift, the next shift will continue to try to reach the family and the resident will be placed on the 24-hour report. The resident will remain on the report until official notification* occurs and is documented in the nurses notes. Attempts should be made every 2-4 hours until contact is made. Social Services shall be notified of failure 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, clinical record review, and interview with staff, it was determined that the facility failed to provide discharge planning that focuses on the resident's discharge goals and preparation of residents to be active partners in the discharge planning process that focuses on the resident's discharge planning and process for one of four residents (Resident R1). Findings include: Review of the facility Transfer and Discharge policy last reviewed 9/30/22, states the facility is required to provide sufficient preparation and orientation to residents to ensure safe and orderly discharge from facility. Review of the clinical record indicated Resident R1 was admitted on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/18/23, indicated diagnoses of heart failure, hypertension, and renal failure. Section C. Cognitive Patterns indicated the resident had a BIMS (Brief Interview for Mental Status-is a mandatory tool used to screen 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 clinical record review and staff interview, it was determined that the facility failed to ensure a follow-up appointment with a cardiologist was scheduled as ordered for one of three residents reviewed (Resident R1). Findings include: Review of the facility Transcribing Physician Orders policy last reviewed 9/30/22, states Consult requests will be called to the ordered consultant to notify and schedule the consult. The notification and scheduled date will be documented in the nursing process notes and on the unit's calendar. Review of the clinical record indicated Resident R1 was admitted on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/18/23, indicated diagnoses of heart failure, hypertension, and renal failure. Review of resident R1's physician order dated 5/18/23, stated the resident had a follow-up appointment with heart and vascular on 6/19/23 at 10:00 a.m. During an interview on 8/22/23, at 2:00 p.m., the Director of Physician services,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure an appointment with an ophthalmologist and/or audiologist was scheduled as ordered for two of three residents (Residents R4 and R10.) Findings include: Review of the facility Transcribing Physician Orders policy last reviewed 9/30/22, states Consult requests will be called to the ordered consultant to notify and schedule the consult. The notification and scheduled date will be documented in the nursing process notes and on the unit's calendar. Review of the clinical record indicated Resident R4 was admitted on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/18/23, indicated diagnoses of high blood pressure, alcohol abuse, and seizures. Section B: Hearing, Speech, and Vision indicated the resident had moderate difficulty hearing and has impaired vision. Review of Resident R4's physician order dated 6/12/23, indicated the facility may consult audiology 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.