Glen Brook Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, the Resident Assessment Instrument (RAI), and staff interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments accurately reflected the status of two residents out of 35 sampled (Residents 2 and 183). Findings include: According to the Resident Assessment Instrument (RAI) User's Manual (an assessment tool utilized to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan, and the RAI also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status) dated October 2024, Section A2105: Discharge Status indicates to review the medical record, including the discharge plan and discharge orders, for documentation of discharge location. This section indicates that if the resident is discharged to a private home, apartment, board and care, assisted living facility, group home, transition living, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of clinical records and staff interviews, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included specific and individualized interventions to address a resident's involuntary movements for one out of five residents sampled for unnecessary medication (Resident 10). Findings include: A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder (a condition in which an individual has a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania, and a milder form of mania called hypomania). A clinical record review revealed an Abnormal Involuntary Movement Scale (AIMS- assessment tool used to screen for and assess the severity of tardive dyskinesia (TD), a movement disorder that can occur as a side effect of certain medications, particularly antipsychotics) dated September 23, 2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records, select facility policy, and staff interview it was determined the facility failed to consistently administer Oxygen (O2) as ordered for one out of 35 sampled residents (Resident 14). Findings included: Review of the facility Oxygen Administration Policy last reviewed April 17, 2024, indicated that oxygen is administered to residents who need it, consistent with professional standards, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen is administered under the orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. A review of the clinical record of Resident 14 revealed admission to the facility on November 1, 2024, with diagnoses that include congestive heart failure (the heart muscle does not pump blood as well as it should). The resident had a current physician order initially dated December 16, 2024, for O2 at 2 liters per minute (L/min) continuous via…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and resident and staff interviews, it was determined the facility failed to timely follow up with required dental services for one Medicaid payor source resident out of 35 residents sampled (Resident 10). Findings include: A clinical record review revealed Resident 10 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and mild protein malnutrition (inadequate intake of food, particularly protein and calories, resulting in a deficit in expected weight for age or height). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 3, 2025, revealed that Resident 10 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section 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 a review of clinical records and staff interview, it was determined the facility failed to offer and/or provide the influenza immunization, unless the immunization was medically contraindicated or the resident had already been immunized, for one out of the five residents sampled (Resident 58). Findings include: A review of the clinical record revealed that Resident 58 was admitted to the facility on [DATE], with diagnoses to include chronic atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 6, 2025, revealed that Resident 58 is severely cognitively impaired with a BIMS score 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, select facility policy and incident reports, and staff interviews, it was determined that the facility failed to implement adequate safety measures, including sufficient staff supervision, for a resident identified as at high risk for falls to prevent falls for one resident out of 35 sampled (Resident 115). Findings include: A facility policy titled Falls Prevention Program, last reviewed by the facility in April 2024, revealed that each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The policy indicates the facility will provide interventions as directed by the resident's assessment, including but not limited to assistive devices, increased frequency of safety monitoring rounds, scheduled ambulation or toileting assistance, and therapy services referrals. A clinical record review revealed Resident 115 was admitted to the facility on [DATE], with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's abuse prohibition policy, select investigative reports and clinical records, and staff interview, it was determined the failed to ensure the provision of care and services necessary to prevent a fall and maintain the physical health of one resident (Resident B1) out of two residents reviewed Findings include: A review of the facility policy titled Abuse, Neglect and Exploitation last reviewed by the facility on April 15, 2024, revealed it is the facility's policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The policy defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A clinical record review revealed that Resident B1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined the facility failed to develop and/or implement a person-centered comprehensive care plan for three residents out of 35 sampled (Resident 103, 58, and 404). Findings include: A review of the clinical record revealed Resident 103 was admitted to the facility on [DATE], with diagnoses to include Type 2 diabetes and difficulty walking. A review of a bowel and bladder assessment dated [DATE], revealed the resident is always incontinent of urine and feces. A review of the resident's clinical record revealed the resident is on a two hour check and change program to check for incontinence. A review of the current resident's plan of care revealed the resident's care plan failed to identify the resident's bowel and bladder incontinence and interventions to address the resident's concerns. A review of Resident 58's clinical record revealed that the resident was admitted to the facility July 30, 2023, with diagnoses that included dementia 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 a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to administer medication timely in accordance with physician's orders for one resident out of 35 sampled (Resident 161). Findings include: A facility policy titled Medication Administration, last reviewed by the facility in April 2024, revealed medications are administered by licensed nurses or other staff who are legally authorized to do so, as ordered by the physician and in accordance with professional standards of practice. The policy states that licensed nurses shall Administer medications within 60 minutes prior to or after scheduled time unless otherwise ordered by physician or resident preference. A clinical record review revealed Resident 161 was admitted to the facility on [DATE], with diagnoses that include end-stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs). Further clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, and resident and staff interviews, it was determined the facility failed to ensure residents receive appropriate services and assistance to maintain or improve mobility with the maximum practicable independence for two out of 35 residents sampled (Residents 145 and 180). Findings include: A clinical record review revealed Resident 145 was admitted to the facility on [DATE], with diagnoses that included dorsopathy (diseases of the spine and vertebral tissues accompanied by pain in the back) and morbid obesity (a chronic disease that's characterized by a body mass index of 40 or higher, or a body mass index of 35 or higher with obesity-related health issues). A Physical Therapy (PT) Discharge summary dated [DATE], revealed discharge recommendations for Resident 145 to have a restorative range of motion program. Specifically, the recommendations include bilateral lower extremity range of motion in recline and sitting positions and daily out of bed to wheelchair and range 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, select facility policy and investigative reports resident and staff interview, it was determined that the facility failed to ensure that one resident was free from physical abuse out of 9 sampled residents (Resident C1). Findings including A review of the current facility policy titled Abuse, Neglect and Exploitation, last reviewed by the facility February 7, 2024, revealed that it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. A review of Resident C1's clinical record revealed admission to the facility on July 15, 2022, with diagnoses, of Alzheimer's dementia [chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by…

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

Based on review of select facility policy and staff interview, it was determined that the facility failed to fully develop and implement an abuse prohibition policy with corresponding written procedures to assure staff carry out the tasks necessary to fulfill required components for abuse prevention. Findings include, A review of a facility policy for, Abuse, Neglect and Exploitation reviewed February 7, 2024 revealed guidelines to include: 1. The facility will develop and implement written policies and procedures that; a. Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property. b. Establish policies and procedures to investigate any such allegations The abuse policy did not include Involuntary seclusion as a form of abuse or any definitions of the types of abuse included in the policy. Screening procedures included: A. Potential employees will be screened for a history of abuse, neglect, exploitation or misappropriation of resident property. 1. Background, reference, and credential's checks shall be conducted on potential…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 select facility policy and resident and staff interview it was determined that the facility failed to provide pharmacy services to assure consistent availability of routine prescribed pharmaceuticals and medications for four of nine residents reviewed (Residents B3, B4, B5, and C4). Findings include: A review of the facility's policy titled Ordering and Receiving Non-Controlled Medications provided by facility during the survey of March 28, 2024, and dated as last reviewed by the facility August 2020, indicated that repeat medications (refills) are written on a medication reorder form or by peeling the reorder tab from the prescription label and placing it in the appropriate area on the medication reorder form provided by the pharmacy, or requested via the facility's EHR (Electronic Health Record) system. A review of the clinical record revealed that Resident B3, was admitted to the facility on [DATE], with diagnosis to include diabetes. Current physician orders 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.

Based on observations, review of the statement of deficiencies from the surveys ending February 6, 2024, and February 28, 2024, and the activities of facility's quality assurance committee and staff interviews it was determined that the facility failed to implement effective plans to correct quality deficiencies in pharmacy services, timely obtaining resident medications, and accurate clinical records to ensure that corrective action plans designed to improve the delivery of care and services were consistently implemented to correct and deter future quality deficiencies. Findings included: During the survey ending February 28, 2024, quality deficiencies were cited under the requirements for pharmacy services due to the facility's failure to timely obtain resident medications and clinical records for failing to maintain accurate and complete medical records reflecting the resident's experience in the facility. In response to these deficiencies, the facility developed a plan of correction to correct these deficient practices that included quality assurance monitoring plans to assure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interview, it was determined that the facility failed to timely develop and implement a person-centered care plan to meet one resident's current needs for the use of an implantable cardiac devices for one of nine sampled residents (Resident B1). Findings including: Clinical record review revealed that Resident B1 was admitted to the facility on [DATE], with diagnoses to include A-V block (atrioventricular block (AV block) is a disease of the electrical conduction system of the heart in which electrical impulses conduct from the cardiac atria to the ventricles through the atrioventricular node (AV node) more slowly than [NAME] and heart disease), implantable cardiac pacemaker and hypertensive chronic kidney disease with heart failure. Review of quarterly Minimum Data Set Assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 7, 2024, revealed that Resident B1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and select investigative reports and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for one of nine sampled residents (Resident A1). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. According to the Title…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and a review of employee personnel records it was determined that the facility failed to provide abuse prevention training to one employee out of five reviewed. (Employee 2). Findings include: During an interview with Employee 2 (agency LPN) on March 28, 2024 at 9:45 a.m she stated that this was the first shift she worked at the facility. Employee 2 stated that she was never trained on the facility's abuse prohibition policy prior to assuming her duties today. There was no documentation that Employee 2 was trained on the facility's abuse prohibition policies and procedures as part of staff orientation and training on the prohibition of all forms of abuse, neglect, and exploitation prohibition. Interview with the Administrator on March 28, 2024 at 11:15 a.m., confirmed that the facility had no written records to show that Employee 2 was trained on the facility's policy and procedures on as part of staff orientation and training before assuming job duties. 28 Pa. Code 201.20 (b) Staff development 28 Pa. Code 201.19 (7) Personnel policies and procedures

Based on a review of grievances lodged with the facility and select facility policy and resident and staff interviews it was determined that the facility failed to demonstrate timely and adequate efforts to resolve resident grievances for two residents out of 16 sampled. (Resident 2 and 11) Findings include: A review of facility policy entitled Resident and Family Grievances revealed the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. The staff will forward the grievance form to the grievance official as soon as practicable. The grievance official takes steps to resolve the grievance and record information about the grievance and those actions on the grievance form. In accordance with the residents right to retain a written decision regarding his or her grievance, the grievance official will issue a written decision of the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility policy and resident and staff interviews it was determined that the facility failed to provide timely care and necessary resident care supplies for effective incontinence management for one resident out of 16 sampled (Resident 2). Findings included: A review of a facility policy entitled Urinary and Bowel Incontinence last reviewed by the facility on October 3, 2023, indicated that it was the policy of the facility that once a resident was identified as incontinent, staff would develop a plan of care to manage issues with incontinence and provide the appropriate treatment and services to meet the resident's toileting needs. A review of Resident 2's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included diabetes, congestive heart failure and above the knee amputation of the right leg and below the knee amputation of the left leg. The resident's plan of care for ADL (activities of daily living include…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 select facility policy and resident and staff interview it was determined that the facility failed to implement pharmacy procedures to consistent availability of routine prescribed medications for one of 16 residents reviewed (Resident 8). Findings include: A review of the facility's policy titled Ordering and Receiving Non-Controlled Medications provided by facility on February 28, 2024, indicated that repeat medications (refills) are written on a medication reorder form or by peeling the reorder tab from the prescription label and placing it in the appropriate area on the medication reorder form provided by the pharmacy, or requested via the facility's EHR (Electronic Health Record) system. Resident 8 was admitted to the facility on [DATE], with diagnosis to include diabetes with hyperglycemia (high blood sugar), and hypertension (elevated blood pressure). Review of current physician orders for Resident 8 revealed an order for Novolin 70/30 subcutaneous suspension…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adhere to expiration dates on pharmacy products stored in the central supply room. Findings include: Observations of the facility's central supply room on February 28, 2024, at 11:15 AM revealed one box, containing 5 bottles of Glucerna tube feeding, and another box containing 6 bottles, both had expired in [DATE]. There were 2 bags Nova Source Renal tube feeding formula that expired [DATE]. 16 bottles of hand sanitizer expired in [DATE]. An interview with Employee 5, clinical consultant ,on February 28, 2024, at the time of the observation confirmed the pharmacy products, enteral tube feeding formulas had expired . 28 Pa. Code 211.9 (k) Pharmacy Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and staff interviews, it was determined that the facility failed to consistently provide residents dependent on staff for assistance with activities of daily living, the necessary services to maintain good personal hygiene by failing to provide showers as scheduled for one resident out of 16 residents sampled (Resident 2). Findings include: A review of Resident 2's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included diabetes, congestive heart failure (CHF - heart disease that affects pumping action of the heart muscles that causes fatigue, shortness of breath) and above the knee amputation of the right leg and below the knee amputation of the left leg The resident's plan of care for ADL (activities of daily living include bathing, dressing, combing hair, etc.) assistance initiated on July 7, 2022, and revised on November 12, 2023, indicated that Resident 2 had an ADL self-care deficit related to an amputation 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.

Based on observation and staff interview, it was determined that the facility failed to store resident care supplies in a sanitary environment and manner in the central supply room. Findings included Observations of the facility's central supply room on February 28, 2024, at 11:15 AM revealed paper litter, dirt, and debris scattered about the floor of the room. There were boxes of personal care supplies directly on the floor, including bags of clean incontinence briefs, boxes of skin and hair cleanser. An oxygen tubing and mask kit was observed on the floor. A skin stapler remover kit was observed on the floor. A foam dressing kit and a piston syringe was observed on the floor. Outside the central supply room, there were 20 boxes of clean incontinence briefs on the floor. An interview with Employee 5 clinical consultant on February 28, 2024, at the time of the observation confirmed the supplies were not stored appropriately. During an interview with the DON (Director of Nursing) on February 28, 2024 at approximately 4:00 PM revealed the central supply room is to be maintained in a…

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

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and on two of four resident pantries. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observation on the East Nursing Unit during the lunch meal on February 6, 2024, at 12:50 PM revealed that Resident meal trays…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interview, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life and respect for each resident's dignity and individuality by failing to respond to timely to residents requests for assistance as reported by four residents (Residents 84, 104,176 and 181), timely return a resident's personal clothing for one resident (Resident 182), conduct a dignified dining experience as evidenced by one resident observed (Resident 81), and failed distribute or post menus to afford residents the right to review planned meals to enhance their quality of life as reported by two residents (Resident 172 and 84) out of 27 residents sampled. Findings include: Clinical record revealed that Resident 182 was admitted to the facility on [DATE], with diagnoses to include acute and chronic respiratory distress syndrome (lung condition where organs have inadequate oxygen supply due to fluid buildup in the lungs) 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 observation and staff interview, it was determined that the facility failed to provide housekeeping services to maintain a clean environment on two of four nursing units (Spruce Unit and [NAME] Unit). Findings include: An observation on February 6, 2024, at approximately 9:00 AM, the hallway connecting [NAME] and Spruce Wing revealed a visible accumulation of dirt and debris in two ceiling vents. An observation on February 6, 2024, at approximately 9:09 AM, revealed the floor in resident room [ROOM NUMBER] on the [NAME] Unit felt sticky and an accumulation of debris scattered around the resident's bed. An observation on February 6, 2024, at approximately 10:00 AM, revealed a build-up of white and green stains in the sink in the utility room on [NAME] Wing. An observation of the hall outside the facility's main kitchen on February 6, 2024, at 9:15 AM revealed a thick layer of dust in the ceiling ventilation system. Observation of the resident pantry located on the Spruce Wing on February 6, 2024, at 2:00…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, a review of clinical records, and staff interviews it was determined that the facility failed to provide and/or efficiently deploy sufficient nursing staff to consistently provide timely quality of care, services, and supervision necessary to maintain the physical and mental well-being of the residents in the facility. Findings include: A review of clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses to include dysphagia (difficulty swallowing) and anxiety disorder. A review of Resident 81's clinical record revealed that the resident had a diagnoses of dysphagia (difficulty swallowing), hypertension, and adjustment disorder. A review of clinical record revealed Resident 21 was admitted to the facility on [DATE], with diagnoses of dementia, difficulty walking, and abnormal posture. Observation on the north nursing unit on February 6, 2024, at approximately 9:00 AM 57 residents were residing on the unit. There was two LPNs (license practical nurses) 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 the facility's plan of correction from the survey of December 8, 2023, and the findings of the revisit survey ending February 6, 2024, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement corrective action plans to prevent continued quality deficiencies related to abuse and acceptable practices for the storage and service of food and to ensure that plans designed to improve the delivery of care and services were consistently implemented to effectively deter future quality deficiencies. Findings include: The facility's deficiencies and plan of correction for the survey ending December 8, 2023, revealed that the facility developed a plan of correction that included quality assurance monitoring systems to ensure that solutions were sustained. The results of the current survey ending February 6, 2024, revealed that a thorough investigation of potential abuse had not been completed and continued deficient practice was identified related to this lack of investigation. In response 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 review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to afford a resident the right to make choices regarding their preferences for daily routines, choice of daily clothing, for one resident out of 27 sampled (Resident 137). Findings include: A review of Resident 137's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include cerebral infarction (stroke), left hemiplegia and hemiparesis, osteoarthritis, and gastro-esophageal reflux disease (GERD). A review of a Annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 6, 2024, section F - preferences for customary routine and activities, indicated that it is very important to the resident for him to choose what clothes to wear. Resident 137's care plan (a guide used to assist in directing resident care) indicated that the resident had an 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 a review of clinical records, information submitted by the facility, and select investigative reports and resident and staff interviews it was determined that the facility failed to conduct a thorough investigation into an allegation of physical abuse and report the results of the investigation to the State Survey Agency within 5 working days of the incident for one resident out of 25 sampled (Resident 81). Findings include: During the survey ending February 6, 2024, the survey team made multiple requests for the facility's current abuse prohibition policy, but the facility did not provide the policy by the conclusion of the survey. A review of Resident 81's clinical record revealed admission to the facility on December 29, 2022, with diagnoses, of diabetes. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively intact with a BIMS (brief interview for mental status - a tool to assess cognitive status) of 14. A review of Resident 1's clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of clinical records, and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure that licensed and professional nurses thoroughly assessed resident status and provided the nursing care required by two residents out of 27 sampled (Resident 181). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: · Assessments · Clinical problems · Communications with other health care professionals regarding the patient · Communication 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 observation and clinical records, resident and staff interview it was determined that the facility failed to follow physician orders for oxygen therapy prescribed for one resident out 27 sampled (Resident 182). Findings include: A review of the clinical record revealed that Resident 182 was admitted to the facility on [DATE], with diagnoses to include acute and chronic respiratory distress syndrome (lung condition where organs have inadequate oxygen supply due to fluid buildup in the lungs) and severe persistent asthma (chronic respiratory condition caused by inflammation and constriction of the airway, causing shortness of breath, wheezing and cough). A review of the resident's care plan for altered respiratory status/difficulty breathing related to respiratory failure dated December 30, 2023, and revised January 10, 2024, revealed that the resident's goal was to have no signs or symptoms or complications related to shortness of breath. Interventions planned were to follow physician order for oxygen.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, test tray results, a review of minutes from the facility's food committee meeting, and resident and staff interviews it was determined that the facility failed to serve food and beverages at palatable and appetizing temperatures on one of four nursing units (East Wing). Findings include: According to the federal regulation 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. A review of the minutes from the facility's food committee meeting that was conducted by the facility's foodservice director on January 8, 2024, revealed that some food items were not hot enough over the weekend (grilled cheese and soup), spaghetti noodles at times stuck together, and some vegetables were overcooked. During interview with a resident who wished to remain anonymous on February 6, 2024, at 11:30 AM the resident stated that the kitchen is trying but that at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and select investigative reports and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for one of 27 sampled residents (Resident 93). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. According to the Title 49,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 grievances lodged with the facility and the minutes from Residents' Council meetings and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by seven alert and oriented residents out of 11 residents interviewed during a group meeting (Residents 9, 53, 57, 85, 123, 165, and 147). Findings include: A review of grievances filed with the facility revealed a grievance filed on August 3, 2023, on behalf of a resident, indicating that care is lacking on the evening shift. The resident indicated that staff did not assist her with care and that she needed to provide her own care. A grievance was filed on August 19, 2023, by a resident, indicated that staff left him in a wet brief. The resident indicated that staff said they would be right back but did not return. A grievance was filed on September 8, 2023, on behalf of a resident, indicated that the resident did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 select incident reports and staff interview it was determined that the facility failed to fully develop and implement person-centered comprehensive care plans to meet the individualized toileting and safety needs of two residents (Residents 161 and 278) out of 35 sampled. Findings included: A review of Resident 161's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included dementia, cognitive communication deficit [may occur after a stroke, tumor, brain injury, progressive degenerative brain disorder, or other neurological damage and can result in difficulty with thinking and how someone uses language], muscle weakness, and abnormal GAIT (walking pattern) and mobility. A review of a Resident 161's quarterly-Day MDS (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 2, 2023, revealed that the resident had severe cognitive impairment,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, a review of select facility policies, and resident and staff interviews, it was determined that the facility failed to maintain a clean, orderly, comfortable, and homelike environment in resident rooms on two of the 10 resident units (E Hall and [NAME] Hall Nursing Units) and failed to allow one resident out of 11 interviewed to use his personal belongings (Resident 123). Findings include: A review of facility policy titled Resident Environmental Quality', dated as implemented on April 15, 2023, revealed that it is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The policy indicates that resident rooms should be at a comfortable temperature for the resident. Resident behavior should be observed (wearing sweaters, wrapping in blankets, etc.) to determine the appropriate temperature level. The policy also indicates that facility personnel are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's abuse policy, clinical records, information submitted by the facility, and select investigative reports and resident and staff interviews it was determined that the facility failed to conduct a thorough investigation into an allegation of physical abuse and report the results of the investigation to the State Survey Agency within 5 working days of the incident for one resident out of 25 sampled (Resident 26). Findings include: A review of the current facility policy titled Abuse, Neglect and Exploitation, last reviewed by the facility April 15, 2023 revealed that the A review of the current facility policy titled Abuse, Neglect and Exploitation, last reviewed by the facility April 15, 2023, revealed that it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.…

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