Meadowcrest Rehabilitation & Healthcare Center

Based on review of clinical records and staff interview, it was determined that the facility failed to provide documentation of medication regimen reviews (MRR) completed at least monthly for three of seven residents (Resident R7, R41 and R22). Findings include: On 3/5/26, the MRRs for Residents R7, R41 and R22 were requested, for the months of September 2025, through February 2026. During an interview on 3/6/26, at approximately 10:30 a.m. the Nursing Home Administrator confirmed that the facility was unable to locate the MRRs for Residents R7, R41 and R22. During an interview on 3/6/26, at approximately 12:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide documentation of medication regimen reviews completed at least monthly for three of seven residents. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.5(f) Medical records. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to appropriately document treatments for two of four residents (Residents R4 and R1).Findings include: Review of the facility policy, Charting and Documentation dated 1/8/26, previously dated 1/14/25, indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of the facility policy, Dressings, Dry/Clean dated 1/8/26, previously dated 1/14/25, indicated for staff to document that date and time the dressing was changed. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and staff interview, it was determined that the facility failed to offer pneumococcal disease vaccines in accordance with facility policy to seven of nine residents whose vaccines were reviewed. (Residents R5, R8, R14, R16, R12, R7 and R31).Findings include: Review of the facility policy Pneumococcal Vaccine dated 1/8/26 with a previous review date of 1/14/25, indicated that all residents are offered the pneumonia vaccine to aid in the prevention of pneumococcal pneumonia upon admission resident are assess for eligibility and when indicated will be offered the vaccine within 30 days of admission. Review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's immunization documentation record did not include that the Pneumococcal vaccine was offered since admission. Review of the clinical record indicated that Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's immunization…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations and staff interview, it was determined that the facility failed to maintain an effective call system for two of five restrooms accessible to residents.Findings include: During an observation on 3/4/26, at approximately 9:38 a.m. the staff restroom on the Garden nursing unit was unlocked. Observation of the restroom revealed no emergency call light or call cord attached for emergency use. During an observation on 3/4/26, at approximately 10:30 a.m. the staff restroom on the Garden nursing unit was unlocked, with the key hanging off the door knob, accessible to residents. Observation of the restroom revealed no emergency call light or call cord attached for emergency use. During an observation on 3/5/26, at approximately 9:45 a.m. the staff restroom on the [NAME] nursing unit was unlocked, with the key hanging on a magnetic hook approximately waist height, inside the restroom. Observation of the restroom revealed no emergency call light or call cord attached for emergency use. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and resident and staff interview it was determined that the facility failed to maintain the privacy and dignity of one of six residents (Residents R3).Findings include:The facility policy Resident Rights dated 1/8/26, previously dated 1/14/25, indicated that facility residents have the right to a dignified existence. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/25/26, included Crohn's disease (chronic inflammatory bowel disease (IBD) causing severe, long-term inflammation) and history of a stroke. Review of Section C: Cognitive Patterns indicated Resident R3 was cognitively intact.During an interview completed on 3/5/26, at 9:08 a.m. Resident R3 stated that she was uncomfortable using the shower room on her nursing unit because a male resident's room opens directly into the shower room through an unlocked door. Observation 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 facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop person-centered care plans for one of six residents (Resident R41).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2025, indicated that Section V: Care Area Assessment (CAA) Summary instructions stated, For each triggered care area, Column B Care Planning Decision is checked to indicate that a new care plan, care plan revision, or continuation of the current care plan is necessary to address the issue(s) identified in the assessment of that care area. Review of the facility policy Care Plans, Comprehensive Person-Centered dated 1/8/26, previously dated 1/14/25, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, 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, facility policy review, and staff interviews, it was determined that the facility failed to ensure opened vials were labeled in accordance with currently accepted professional principles for one of one medication rooms([NAME] Medication Room) and medications obtained from the emergency machine for a resident were labeled in accordance with currently accepted professional standards for one of two medication carts ( [NAME] Medication Cart). Findings include:Review of facility policy Medication Labeling and Storage, dated 1/8/26, with a previous review date of 1/14/25, indicated multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Labeling of medications dispensed by the pharmacy is consistent with applicable federal and state requirements.During observation of the [NAME] medication storage room on 3/4/26, at 11:08 a.m., revealed one vial of tuberculosis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for the one of five residents (Residents R1). Findings include: Review of facility's policy Comprehensive Assessments and Care Delivery Process dated 1/4/25, indicated comprehensive assessments, care planning, and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions.Review of the clinical record indicated Resident R1 was initially admitted to the facility on [DATE], and readmitted on [DATE].Review of Minimum Data Set (MDS - periodic review of resident needs) dated 10/26/25, included diagnoses of parkinsonism (term for neurological conditions causing movement similar to Parkinson's disease), bipolar disorder (a mental illness causing extreme shifts in moods), and anxiety disorder (a mental illness…

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

Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to protect residents from resident-to-resident sexual abuse. This failure resulted in a resident with a known history of sexually inappropriate behavior engaging a non-consenting resident for one of 44 residents (Resident R2).Findings include:Review of the facility-provided Nursing Home Administrator (NHA) job description indicated, 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.Review of the facility-provided Director of Nursing (DON) job description indicated, To plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current federal,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy and clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions for when the individual is incapacitated) or conduct periodic review of instructions for two of five residents reviewed (Residents R1 and R2).Findings include:A review of the facility policy Advance Directives reviewed 1/14/25, indicated upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical recordReview 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews it was determined the facility failed to meet the dietary needs for three of eight residents (Resident R2, R3, and R4). Findings include: Review of Resident R2's record indicated the resident was admitted to the facility on [DATE]. Review of the facility diagnosis list included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), chronic kidney disease (gradual loss of kidney function), and high blood pressure. Review of Resident R2's hospital discharge paperwork dated 7/11/25, indicated Diet Rx: Cardiac, 2 gm NA (diet that restricts sodium intake to 2000 milligrams daily, often recommended for patients with heart failure, high blood pressure, and other conditions where fluid retention is a concern). Review of the admission Assessment completed on 7/11/25, at 8:25 p.m. revealed that the box for 2 gm NA was not checked. Review of Resident R2's current physician orders on 7/22/25, failed to include 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 facility policy, resident choice menu selections, and meal observations, it was determined that the facility failed to provide resident selected menu items for four of nine residents (Resident R5, R6, R7, and R8). Findings include: Review of the facility policy, Resident Food Preferences dated 1/4/25, indicated Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Review of Resident R5's admission record indicated the resident was admitted to the facility on [DATE]. Review of the facility diagnosis list included diagnoses of Salmonella sepsis (a severe, life-threatening infection where Salmonella bacteria enter the bloodstream and spread throughout the body) and a skin abscess (localized collection of pus within the skin). Review of Resident R5's hospital referral dated 7/2/25, noted 38 times that Resident R5 has a history of celiac disease (an illness caused by an immune reaction to eating gluten. Gluten is a protein found in foods…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and documents, clinical records, and staff interviews, it was determined that the facility failed to provide prescribed treatment and services related to the care of a PICC line (peripherally inserted central catheter, a long, thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) for one of two residents (Resident R1).The facility policy Midline Dressing Changes dated 1/4/25, indicated to Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the facility diagnosis list included diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and sepsis (infection in the bloodstream). Review of the nursing admission assessment completed on 7/13/25, at 11:03 p.m. indicated Resident R1 had a PICC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interviews, it was determined that the facility failed to the notify resident representative and/or medical provider of a change in condition or care for three of ten residents (Resident R41, R100, and R143). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the clinical record indicated Resident R41 was admitted to the facility on [DATE]. Review of Resident R41's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/16/25,…

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.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for four of eight residents (Resident R2, R9. R12, and R31). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2024, indicated that Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood. Section D: Mood, Question D0100 Should Resident Mood Interview Be Conducted? should be coded as 0 if the resident is rarely/never understood, and or it should be coded 1, and the assessment should be completed if the resident is at least sometimes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for three of eight residents (Residents R20, R27, and R96). Findings include: Review of facility's policy Comprehensive Assessments and Care Delivery Process dated 1/4/25, indicated comprehensive assessments, care planning, and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. Review of the clinical record revealed that Resident R20 was admitted to the facility on [DATE]. Review of Resident R20's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/31/25, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation and staff interviews, it was determined that the facility failed to develop, implement, and maintain an effective training program, including additional training topics based on the resident population, outcome of the facility assessment, or non-common procedures for two of four Nurse Aides (NA) (Employee E1 and E2). Findings include: Review of information published by the American Cancer Society dated 11/22/19, indicated, Chemotherapy drugs are considered to be hazardous to people who handle them or come into contact with them. For patients, this means the drugs are strong enough to damage or kill cancer cells. But this also means the drugs can be a concern for others who might be exposed to them. Flush the toilet twice after you use it. Put the lid down before flushing to avoid splashing. If possible, you may want to use a separate toilet during this time. If this is not possible, wear gloves to clean the toilet seat after each use. Review of the Facility Assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of four residents (Resident R27). Findings include: Review of facility's policy, Prevention of Pressure Ulcers/Injuries dated 1/4/25, indicated for staff to review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Review of the clinical record revealed that Resident R27 was admitted to the facility on [DATE]. Review of the admission assessment dated [DATE], indicated Resident R27 was admitted with pressure ulcers on his left and right heels. Review of Resident R27's Minimum Data Set (MDS, periodic assessment of resident care needs) 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 documentation and staff interviews, it was determined that the facility failed to provide a safe environment for one of two residents (Resident R22). Findings include: Review of information published by the American Cancer Society dated 11/22/19, indicated, Chemotherapy drugs are considered to be hazardous to people who handle them or come into contact with them. For patients, this means the drugs are strong enough to damage or kill cancer cells. But this also means the drugs can be a concern for others who might be exposed to them. Flush the toilet twice after you use it. Put the lid down before flushing to avoid splashing. If possible, you may want to use a separate toilet during this time. If this is not possible, wear gloves to clean the toilet seat after each use. Review of the Facility Assessment dated 1/4/25, indicated in the previous twelve months, the facility had cared for zero residents that received chemotherapy. Review of the clinical record indicated Resident R22 was…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for ten of ten staff members (Employees E1, E2, E3, E4, E5, E6, E7, E8, E9 and E10). Findings include: Review of the policy Inservice Training dated 1/4/24, with previous review date of 3/21/23, indicated it is the policy of this facility that all staff participate in regular in-service education upon hire and annually and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. Trainings included for all existing and newly hired employees include but not limited to communication, abuse, neglect, etc, the facility QAPI program and behavioral health. Review of facility provided documents and training record for E1, E2, E3, E4, E5, E6, E7, E8, E9 and E10 revealed the following staff members did not have documented training on QAPI. Nurse Aide (NA) Employee E1 had 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 the facility policy, clinical records, and staff interviews it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for five of six residents reviewed (Resident R1, R2, R12, R20, and R35) Findings Include: A review of the facility policy Advanced Directives reviewed 3/21/23 and 1/4/2024, indicated advance directives will be respected in accordance with state law and facility policy. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. A review of the clinical record indicated Resident R1 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, Non- ST Elevation Myocardial Infarction (NSTEMI- type of heart attack that usually happens when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a clean, homelike environment on two of two nursing units ([NAME] Lane and Garden Lane) and failed to provide a homelike environment for seven of 21 residents of the Garden Lane nursing unit (Residents R24, R4, R22, R34, R25, R16 and R17). Findings include: Review of the facility policy Homelike Environment, last reviewed on 1/4/24, indicated that the facility will ensure that residents are provided with a safe, clean, comfortable, homelike environment and encouraged to use their personal belongings. During an observation on 5/14/24, from 6:32 a.m., through 7:20 a.m., the following was identified: -The main resident lounge located on [NAME] Lane nursing unit had six wheelchairs, a Hoyer lift and a floor scale which did not allow access for resident use. -The dining room at the end of [NAME] hall had a broken baseboard heating unit allowing for sharp edges to be protruding. -The dining…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (Infection Preventionist) for three of four quarterly meeting (May 2023 through July 2023, August 2023 through October 2023, and November 2023 through January 2024). Findings Include: Review of the facility policy Quality Assurance and Process Improvement Committee (QAPI) reviewed 1/4/24, indicated that the facility will establish and maintain a QAPI committee that consists of the administrator, director of nursing, medical director, and infection control representative. Review of QAPI sign in sheets and attendance records from May 2023 through January 2024 failed to indicate the infection control representative was in attendance for any meetings. During an interview on 5/17/24, at 10:10 a.m. the Nursing Home Administrator confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview and facility documents, it was determined that the facility failed to provide training on behavioral health for three of ten staff members reviewed (Employees E4, E5 and E8). Findings Include: Review of the policy Inservice Training dated 1/4/24, with previous review date of 3/21/23, indicated it is the policy of this facility that all staff participate in regular in-service education upon hire and annually and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. Trainings included for all existing and newly hired employees include but not limited to communication, abuse, neglect, etc, the facility QAPI program and behavioral health. Review of facility provided education records for three of the ten currently employed staff members that were reviewed revealed the following: Review of the facility provided current staff list indicated Housekeeping Employee E4 was hired on 12/29/23. housekeeping employee E4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of three residents (Resident R23). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS - mandated assessments of a resident's abilities and care needs), dated October 2023, indicated the following instructions: -Section O: Special Treatments, Procedures, and Programs: Check all of the following treatments, procedures, and programs that were performed during the last 14 days. Review of the clinical record indicated Resident R23 was re-admitted to the facility on [DATE], with diagnoses that included moderate intellectual disabilities, dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to prevent food items from being stored in a medication refrigerator in one of two medication rooms ([NAME] Nursing Unit). Findings include: Review of the facility policy Medication Labeling and Storage dated 3/21/23 and 1/4/24, indicated medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. During an observation on 5/15/24, at 1:35 p.m. revealed the following two Fuji brand water bottles, one [NAME] sparking water bottle, and one small carton of whole milk stored in the medication refrigerator in the [NAME] Nursing Unit medication room. During an interview on 5/16/24, at 1:38 p.m. the Registered Nurse Employee E13 confirmed food and drinks should not be stored in the medication refrigerator. During an interview on 5/16/24, at 2:00 p.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 facility policy review, clinical record review, resident and staff interviews, it was determined that the facility failed to provide nephrostomy (drain from the kidney using a catheter tube) care and services consistent with professional standards of practice for one of three residents with indwelling catheters (Resident R1). Findings include: Review of facility policy Care of Nephrostomy Tube last reviewed 1/13/23, indicated to empty the drainage bag once per shift and as needed and record in the medical record. Review of the clinical record indicated Resident R1 was re-admitted to the facility on [DATE], with diagnoses that included obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow). Review of Resident R1's MDS (Minimum Data Set- resident assessment and care screening) dated 12/14/23, indicated the diagnoses of obstructive uropathy and kidney failure. Section H indicated an indwelling catheter to include a nephrostomy was present. Observation of Resident R1…

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