Sunnyview Nursing And Rehabilitation Center

Based on resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of eleven of 13 residents (Group Resident (GR)1, GR2, GR3, GR4, GR5, GR6, GR7, Resident R16, R64, R113, and R203). Findings Include: During an interview on 7/21/25, at 10:20 a.m. Nurse Aide (NA), Employee E21 was asked how does the facility prevent residents from eloping (leaving a safe area without permission) and replied: We have Wanderguard (a device that alerts staff when a resident leaves a safe area), ones who wander the alarm goes off, elevator locks, and we have to put a code in. When asked if the facility has enough staff to supervise residents, NA Employee E21 replied We have our days, some days residents can have their moments, act up, on those days we can always use more people. During an interview on 7/21/25, at 10:34 a.m. Resident R203 stated the following: All the meals are cold because they're always…

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

Based on review of facility documentation and staff interview it was determined that the facility failed to ensure nurse aides who failed to ensure nurse aides who failed to become certified within four months were not working in the facility for one of four nurse aides ( Nurse Aide trainee Employee E28). Findings include: Review of Title 42 Code of Federal Regulations 483.35(d) Requirement for facility hiring and use of nurse aides -483.35(d)(1) General Rule. A facility must not use any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis unless -(i)that individual is competent to provide nursing and nursing related services; and(ii)(A) That individual has completed a training and competency evaluation program, or a competency evaluation program approved by the State as meeting the requirements of 483.151 through 483.154. Review of facility documentation, witness statement indicated NA trainee Employee E28 was a nurse aide trainee (refer to F689). Review of facility documentation personnel records indicated NA Employee E28 was hired 7/8/24…

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

Based on facility policy, observations, and staff interviews, it was determined that the facility failed to properly label and date food products, failed to ensure hand washing stations were equipped with essential supplies, and failed to maintain the cleanliness and sanitation of equipment in the Main Kitchen. (Main Kitchen).Findings include: Review of the facility policy Food Storage in Refrigerators and Freezers dated 4/12/25, indicated that all foods must be properly labeled and dated. Keep refrigerator clean. Food must be kept 6 inches off of the floor and 12 inches from the ceiling. Review of the facility policy Food Storage Dry Goods: dated 4/1/25, indicated that all food must be dated, labeled and sealed. Keep the floors, walls, ceilings, and shelving clean. During an observation and interview with Food Service Director Employee E14 in the Main Kitchen on 7/21/25, at 10:28 a.m. the following was observed:Refrigerator Number 1 contained a rag with brown and black substances.Refrigerator Number 1 contained a Meat and Cheese Stick Snack that did not have a label with a name or…

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

Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to prevent the elopement of two resident (Resident R12, and R37), which created an immediate jeopardy situation for two of 36 residents. Findings include: The job description for the Nursing Home Administrator dated 10/1/18, and revised 6/15/23, stated that the NHA is responsible to establish and maintain systems that are efficient and effective to operate the nursing home in a manner to safely meets residents' needs in accordance with federal, state, and local regulations. The job description for the Director of Nursing dated 10/3/18, specified it is the responsibility of the DON for the organization and oversight of all nursing operations and for the supervision of care for all residents at the facility. Must be knowledgeable of all regulations, guidelines, and best practices that pertain to long-term care. Based on findings identified in this report, the facility failed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, and staff interview it was determined that the facility failed to provide medically related social services for four of four residents reviewed (Resident R2, R13, R153 and R205).Findings include: Review of facility policy Social Services Responsibilities and Medically Related Practices dated 4/1/25, indicated: The facility will provide, based on comprehensive assessment and care plan and the preferences of each resident, medically - related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. Social Services will act as a Liaison with the residents, the resident's family, the staff of the Facility, and the Community. Medically related social services are provided to maintain or improve each resident's ability to control everyday physical needs and working with individual and groups in developing supportive services for residents according to their individual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to provide evidence medication regimen reviews (MRR) were reviewed by the resident's attending physician monthly for three of three residents (Resident R12, R14 and R166).Finding include: Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses of dementia (loss of cognitive functioning- thinking remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), anxiety, and age-cognitive decline. Review of Resident R12's Minimum Data Set (MDS - a period assessment of care needs) dated 4/23/25, indicated diagnoses were current. Review of Resident R12's Medication Review Regimen dated 6/23/25, failed to include a response from the resident's attending physician. A Certified Registered Nurse Practitioner (CRNP) signed the note to the attending physician on 6/30/25, and the decision…

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

Based on staff interviews it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for nine out of 12 months (November through December 2024, and January through July of 2025.Findings include: During an interview on 7/21/25, at 10:25 a.m. Food Service Director (FSD) Employee E14 stated that she had been employed as the Food Service Director since November of 2024, and that she was not a Certified Dietary Manager. When FSD was asked what education she possessed that qualified her as a FSD, she replied none. During an interview on 7/21/25, at 10:25 a.m. Registered Dietitian (RD) Employee E22 stated that she was employed full time. When RD Employee E22 was asked what her role was for the facility she indicated that it was all clinical and did not manage the daily operations of the Main Kitchen. During an interview on 7/21/24, at 3:00 p.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to provide documented evidence that FSD Employee E14 met the qualifications for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R110).Findings include: Review of facility policy Call Light Resident Response/Monitoring/Reporting dated 4/1/25, indicated the call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Review of the clinical record indicated Resident R110 was admitted to the facility on [DATE]. Review of Resident R110's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/1/25, indicated diagnoses of anemia (too little iron in the blood), muscle weakness, and need for assistance with personal care. During an observation on 7/21/25, at 10:22 a.m. Resident R110's call bell was observed hanging from the wall unit at the head of the bed, out of the resident's reach. During an interview on 7/21/25, at 10:26 a.m. Registered Nurse Employee E1 confirmed Resident R110's call…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical records and staff interviews it was determined that the facility failed to follow up on a concern/grievance for a resident (Resident R106).Findings include: Federal Regulation 483.10(i)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. Review of Resident R106 was admitted on [DATE]. Review of Resident R106 MDS dated [DATE], anemia, and need for personal assistance. Review of the clinical record progress notes dated 7/4/25, indicated that Resident R106 family member requested for Resident R106 to receive assistance with eating due to recent weight loss. Review of Resident R106 clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, and staff and resident interviews it was determined was determined that the facility failed to protect resident from neglect for one of three residents (Residents R54).Findings include: Review of the facility Abuse Policy-Prevention and Management last reviewed 4/1/25, stated it is the facility prohibits the mistreatment, neglect, and abuse of residents. Neglect is the failure of the facility, it's employees or service providers to provide goods and services that a resident requires but the facility fails to provide them to the resident. Review of the facility policy Resident Transfer Protocol last reviewed 3/19/25, stated appropriate transfer techniques shall be used according to each resident's strength, stamina, and ability to assist with the residents. Necessity for the amount and type of assistance shall be assessed upon admission and on an ongoing basis. Review of Residents R54's admission record indicated the resident was admitted on [DATE], 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, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of three residents sampled with facility-initiated transfers (Residents R113 and R164).Findings include:Review of the clinical record indicated Resident R113 was admitted to the facility on [DATE]. Review of Resident R113's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and need for assistance with personal care. Review of the clinical record indicated Resident R113 was transferred to the hospital on 4/16/25, and returned to the facility on 4/18/25. Review of Resident R113's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred 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 interviews, it was determined that the facility failed to ensure the comprehensive care plan was implemented related to safety interventions for safe smoking for one of 11 residents (Resident R16).Findings include: Review of facility policy Care Planning Process and Care Conference dated 4/1/25, indicated the care plan is a working tool that provides a profile of the needs of the individual resident/patient; the resident/patient care plan will be available for use by staff caring for the resident. All resident/patient care and interventions must be carried out per the care plan. Review of the clinical record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/4/25, indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and muscle weakness. Review of Resident R16's care plan dated 6/20/23, indicated Resident R16…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide a assistance with toileting for one out of four residents (Resident R54).Findings include: Review of the facility ADL Care, Toileting-Bowel and Bladder Incontinence Care last reviewed 4/1/25, stated for a resident with urinary incontinence, based on resident's comprehensive assessment, the facility will ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence and services to restore to the extent as possible. ADL documentation will be completed by the nurse aides and any refusals must be reported to the supervisor. Review of Residents R54's admission record indicated the resident was admitted on [DATE], and readmitted [DATE]. Review of Residents R54's care plan dated 11/11/22, revised 10/28/24, revealed the resident had an activity of daily living (ADL-the basic self-care tasks…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to notify the physician of medication refusal and increased Capillary Blood Glucose (CBG) levels per physician order and for two of three residents (Residents R153 and R203).Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus (DM) is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to obtain appropriate physician orders for a urinary catheter (insertion of a tube into the bladder to remove urine) for one out of five sampled residents (Resident R218). Findings include: The facility Catheter-foley policy reviewed 4/1/25, indicated that a resident who enters the facility with an indwelling catheter or subsequently receives on is assessed for removal unless the resident's clinical condition demonstrates that catheterization was necessary. Review of Resident R218's admission record indicated she was admitted on [DATE] and readmitted on [DATE]. Review of Resident R218's nursing initial assessment (assessment done upon admission by nursing related to resident care needs) dated 7/18/25, indicated she had diagnoses that included diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), hyperlipidemia (an elevated lipid levels within 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 resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis (a machine that filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for two of three residents (Resident R6, and R182).Findings include: Review of facility policy Dialysis Management (Hemodialysis) dated 4/1/25, indicated the facility will develop a resident binder/folder to send to dialysis with the resident. Communication form is placed in the binder after completion of the pre dialysis assessment. Facility to compete Pre-Dialysis information on the communication form and send with resident to dialysis on treatment days, to ensure communication of resident information and coordinate care between Dialysis Center and facility. Dialysis center personnel to complete Dialysis communication form and return to facility. Upon return from Dialysis Center,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents (Residents R8 and R203).Findings include: Review of facility policy Trauma Informed Care dated 4/1/25, indicated facilities must identify triggers which may re-traumatize residents with a history of trauma. A trigger is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE], with diagnoses of post-traumatic stress disorder (PTSD), depression, and insomnia (difficulty staying or falling asleep). Review of Resident R8's Social Service Quarterly Review dated 4/16/25, revealed when agitated, Resident R8 will yell profanities and can be aggressive. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records and facility policy review, and staff interview, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services for one of three residents (Resident R12).Findings include: Review of the facility policy Suicide Prevention dated 4/1/25, stated it is the policy of the facility to ensure that residents who voice and/or display suicidal ideation actions receive services and interventions to help them manage feelings and maintain their psychosocial wellbeing. Review of Resident R12's admission record indicated he was admitted on [DATE], with diagnoses of dementia (loss of cognitive functioning- thinking remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), anxiety, and age-cognitive decline. Review of Resident R12's MDS (Minimum Data Set a periodic assessment of care needs) dated 4/23/25, indicated the diagnoses were current.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two of six residents reviewed (Resident R12 and R54). Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two of six residents reviewed (Resident R12 and R54). Findings include: Review of the facility Dementia Care policy last reviewed 4/1/25, indicated it is the policy of the facility to improve resident's function regardless of the individual's physical and mental diagnosis. It is the responsibility of each staff member to have a sound, general knowledge of what is pathologically happening to the resident…

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

Based on review of facility policy, review of controlled medication reconciliation records and staff interviews, it was determined that the facility failed to implement procedures to promote accurate accounting of controlled medications on two out of seven medication carts (Cardinal East medication cart and Cardinal South-west medication cart). Findings include: The facility Drug diversion prevention and narcotic management policy dated 4/1/25, indicated that control medications will be counted with two professional nurses at the beginning and end of each shift. Documentation that a count was completed and done accurately will be completed at the beginning and end of each shift. These medications are to be counted each shift until the medications are removed. The controlled substance received will be logged as an addition with a witness on the front of the log. During a review of the Narcotic count record log for the Cardinal East Medication Cart on 7/24/25, at 9:47 a.m. revealed the nursing staff failed to sign the record during shift change to verify counts of controlled drugs on…

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

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in one of seven medication carts (Dogwood [NAME] Medication Cart).Findings include: Review of facility policy Medication Storge dated 4/1/25, indicated the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. During an observation on 7/24/25, at 9:14 a.m. of the Dogwood [NAME] Medication Cart revealed the following outdated medications:Resident R183's Humalog insulin pen (a prefilled pen to inject rapid-acting insulin under the skin), open date 6/17/25, expiration date 7/14/25. During an interview on 7/24/25, at 9:15 a.m. Licensed Practical Nurse Employee E2 confirmed the above observation and that the facility failed to properly store medications in the Dogwood [NAME] Medication Cart. 28 Pa. Code: 201(a) Responsibility of licensee.28 Pa. Code: 211.9(a)(1)(k) Pharmacy services.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and staff interviews it was determined that the facility failed to provide a resident special eating equipment and utensils for one out of five residents (Resident R54).Findings Include: Review of Residents R54's admission record indicated the resident was admitted on [DATE], and readmitted [DATE]. Review of Residents R54's care plan dated 12/16/24, revealed the resident is to receive all disposable items from dietary due to my hoarding for safety/sanitary purposes as my hoarding is an infection control concern. Review of Residents R54's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/22/25, revealed diagnoses of dementia (loss of cognitive functioning- thinking remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), acquired absence of left leg below the knee, and anxiety. During an observation on 7/21/25, at 12:59 p.m. Resident R54 was observed with reusable plate and silverware. The facility failed to provide all…

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

Based on review of facility policy, observation and staff interview it was determined that the facility failed to properly contain and dispose of garbage in one of three outside dumpsters to prevent the potential for rodent and insect infestation (Middle dumpster).Findings include: Review of facility policy Garbage and Rubbish Disposal dated 4/1/25 indicated that outside dumpsters provided by garbage pick-up services must be closed and free of litter around the dumpster area. During an observation and interview of the facility's outdoor trash receptacles on 7/21/25, at 10:45 a.m. Food Service Director Employee E14 confirmed that the lid/cover was not closed on the middle dumpster in the disposal area. 28 Pa. Code 201.18(b)(3) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident records, observations, and staff interview it was determined that the facility failed to ensure enhanced barrier precautions (EBP) were implemented during a dressing change which a created the potential for cross contamination for one out of four sampled residents (Residents R140).Findings include: The facility Transmission Based Precautions policy dated 4/1/25, indicated that enhanced barrier precautions are an infection control intervention designed to reduce transmission of multi-drug resistance organisms (MDRO) in nursing homes. Enhanced barrier precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those with increased risk such as residents with wounds or indwelling medical devices. Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheostomies. Review of Resident R140's admission record indicated the resident was admitted to…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Effective Communication for one of five staff members (Nurse Aide (NA) Employee E6).Findings include: Review of facility policy Staff Development Training Program dated 4/1/25, indicated the following in-service orientation/training classes are mandatory (i.e., each employee must attend a training class on each of the following topics upon hire and at least annually): Accident Prevention and Management, Dementia Training, Infection Control, Resident Rights, Resident Abuse, Fire Safety and Disaster Preparedness, Hazard Communication Plan, Corporate Compliance, QAPI (quality assessment and performance improvement), Communication, Behavior Health, Restorative Nursing, training needs identified through a facility assessment, and training needs identified for job specific skills. Review of NA Employee E6's personnel file indicated a hire date of 12/2/14, and failed to include Effective Communication training between 12/2/23 and 12/2/24. During an…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Resident Rights for one of five staff members (Nurse Aide (NA) Employee E6).Findings include: Review of facility policy Staff Development Training Program dated 4/1/25, indicated the following in-service orientation/training classes are mandatory (i.e., each employee must attend a training class on each of the following topics upon hire and at least annually): Accident Prevention and Management, Dementia Training, Infection Control, Resident Rights, Resident Abuse, Fire Safety and Disaster Preparedness, Hazard Communication Plan, Corporate Compliance, QAPI (quality assessment and performance improvement), Communication, Behavior Health, Restorative Nursing, training needs identified through a facility assessment, and training needs identified for job specific skills. Review of NA Employee E6's personnel file indicated a hire date of 12/2/14, and failed to include Resident Rights training between 12/2/23 and 12/2/24. During an interview on 7/25/25,…

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 facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for one of five staff members (Nurse Aide (NA) Employee E6).Findings include: Review of facility policy Staff Development Training Program dated 4/1/25, indicated the following in-service orientation/training classes are mandatory (i.e., each employee must attend a training class on each of the following topics upon hire and at least annually): Accident Prevention and Management, Dementia Training, Infection Control, Resident Rights, Resident Abuse, Fire Safety and Disaster Preparedness, Hazard Communication Plan, Corporate Compliance, QAPI (quality assessment and performance improvement), Communication, Behavior Health, Restorative Nursing, training needs identified through a facility assessment, and training needs identified for job specific skills. Review of NA Employee E6's personnel file indicated a hire date of 12/2/14, and failed to include Abuse, Neglect, and Exploitation training between 12/2/23 and…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program for one of five staff members (Nurse Aide (NA) Employee E6). Findings include: Review of facility policy Staff Development Training Program dated 4/1/25, indicated the following in-service orientation/training classes are mandatory (i.e., each employee must attend a training class on each of the following topics upon hire and at least annually): Accident Prevention and Management, Dementia Training, Infection Control, Resident Rights, Resident Abuse, Fire Safety and Disaster Preparedness, Hazard Communication Plan, Corporate Compliance, QAPI (quality assessment and performance improvement), Communication, Behavior Health, Restorative Nursing, training needs identified through a facility assessment, and training needs identified for job specific skills. Review of NA Employee E6's personnel file indicated a hire date of 12/2/14, and failed to include QAPI program training between…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Infection Control for one of five staff members (Nurse Aide (NA) Employee E6).Findings include: Review of facility policy Staff Development Training Program dated 4/1/25, indicated the following in-service orientation/training classes are mandatory (i.e., each employee must attend a training class on each of the following topics upon hire and at least annually): Accident Prevention and Management, Dementia Training, Infection Control, Resident Rights, Resident Abuse, Fire Safety and Disaster Preparedness, Hazard Communication Plan, Corporate Compliance, QAPI (quality assessment and performance improvement), Communication, Behavior Health, Restorative Nursing, training needs identified through a facility assessment, and training needs identified for job specific skills. Review of NA Employee E6's personnel file indicated a hire date of 12/2/14, and failed to include Infection Control training between 12/2/23 and 12/2/24. During an interview on…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for one of five staff members (Nurse Aide (NA) Employee E6).Findings include: Review of facility policy Staff Development Training Program dated 4/1/25, indicated the following in-service orientation/training classes are mandatory (i.e., each employee must attend a training class on each of the following topics upon hire and at least annually): Accident Prevention and Management, Dementia Training, Infection Control, Resident Rights, Resident Abuse, Fire Safety and Disaster Preparedness, Hazard Communication Plan, Corporate Compliance, QAPI (quality assessment and performance improvement), Communication, Behavior Health, Restorative Nursing, training needs identified through a facility assessment, and training needs identified for job specific skills. Review of NA Employee E6's personnel file indicated a hire date of 12/2/14, and failed to include Compliance and Ethics training between 12/2/23 and 12/2/24. During an interview…

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

Based on review of facility policy, personnel files and staff interview it was determined that the facility failed to conduct the minimum 12 hours of nurse aide (NA) training per year for one of five NA personnel files (NA Employee E6) and failed to complete annual training on Dementia Management for two of six personnel files (NA Employee E6 and Licensed Practical Nurse (LPN) Employee E7).Findings include: Review of facility policy Staff Development Training Program dated 4/1/25, indicated the following in-service orientation/training classes are mandatory (i.e., each employee must attend a training class on each of the following topics upon hire and at least annually): Accident Prevention and Management, Dementia Training, Infection Control, Resident Rights, Resident Abuse, Fire Safety and Disaster Preparedness, Hazard Communication Plan, Corporate Compliance, QAPI (quality assessment and performance improvement), Communication, Behavior Health, Restorative Nursing, training needs identified through a facility assessment, and training needs identified for job specific skills.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Behavioral Health for one of five staff members (Nurse Aide (NA) Employee E6).Findings include: Review of facility policy Staff Development Training Program dated 4/1/25, indicated the following in-service orientation/training classes are mandatory (i.e., each employee must attend a training class on each of the following topics upon hire and at least annually): Accident Prevention and Management, Dementia Training, Infection Control, Resident Rights, Resident Abuse, Fire Safety and Disaster Preparedness, Hazard Communication Plan, Corporate Compliance, QAPI (quality assessment and performance improvement), Communication, Behavior Health, Restorative Nursing, training needs identified through a facility assessment, and training needs identified for job specific skills. Review of NA Employee E6's personnel file indicated a hire date of 12/2/14, and failed to include Behavioral Health training between 12/2/23 and 12/2/24. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record and staff interview it was determined that the facility failed to ensure that in preparation for a room change each resident/responsible party received written notice, including the reason for the change before the resident room was changed for one of ten (Resident R153).Findings include: Federal regulatory guidance under 483.10( e)(6) notes that moving to a new room or changing roommates is challenging for residents. A resident's preferences should be taken into account when considering such changes. When a resident is being moved at the request of facility staff, the resident, family, and/or resident representative must receive an explanation in writing of why the move is required. The resident should be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move. Review of Resident R153 was admitted to the facility on [DATE]. Review of Resident R153 clinical record MDS (minimum data set a periodic assessment of resident needs)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview it was determined that the facility to ensure that a room change was not completed for staff convenience for one of ten residents (Resident R153).Findings include: Review of Resident R153 was admitted to the facility on [DATE]. Review of Resident R153 clinical record MDS (minimum data set a periodic assessment of resident needs) dated 6/28/25, indicated diagnosis of schizophrenia (mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior), anxiety disorder (are a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation) and seizure disorder (a sudden burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings and levels of consciousness). Review of Resident R153 clinical record - Census indicated she had been in a private room from 6/21/24 till 7/10/25.…

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 a review of facility policies, observations and staff interviews it was determined that the facility failed to make certain that dietary employees properly restrained hair their hair by wearing hair nets and beard guards which created the potential for food borne illness in the Main Kitchen. (Main Kitchen/Cook Employee E2) Findings include: A review of facility policy Personal Hygeine dated 4/1/25, indicated that dietary staff is to properly restrain their hair by wearing hair nets and beard guards. During an observation on 5/13/25, at 12:30 pm [NAME] Employee E2 was observed failing to properly restrain his facial hair (beard) by wearing a beard guard as required. During an interview on 5/13/25, at 2:30 pm Food Service Manager Employee E1 confirmed that [NAME] Employee E2 failed to properly restrain his facial hair which created the potential for food borne illness. Pa Code: 211.6(f) Dietary services

Based on a review of facility policies, standardized recipes, observations, test tray audits, and resident and staff interviews it was determined that the facility failed to follow standardized recipes, and serve food products at palatable temperatures for the lunch meal served on May 13, 2025. ( Lunch meal 5/13/25). Findings include: A review of facility Food Temperatures and Test Tray Audits policy dated 4/1/25, indicated trays will be audited for food temperature, food quality and overall dining experience. Minimum temperatures at the time of service are defined as: soups > (greater than) 135 ° F (Farenheit), milk and milk products <(less than) 45°F, cold entrees<55°F, hot entrees >135°F, starches>135°F, hot vegetables >135°F, cold desserts <55°F, cold beverages <55°F and hot beverages >142°F. During an interview on 5/13/25, at 11:30 am Resident R1 voiced concerns regarding food being served cold and that the food was not good at all. During a review of the facility's grievance log for 4/3/25, Resident R2 voiced a concern regarding the temperature of food products. A review of…

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

Based on a review of facility policies, observations and resident and staff interviews it was determined that the facility failed to provide residents food products based on their preferences for four out of four residents (Resident R1, R3, R4, and R5). Findings include: A review of facility Accuracy and Quality of Tray Line Service dated 4/1/25, indicated that trays are checked for accuracy and resident dislikes. During an interview on 5/13/25, at 11:30 am Resident R1 voiced a concern that she does not receive food products that she requests on her menu. During an observation of tray line services on 5/13/25, it was revealed that Resident R3 and R4 tray cards indicated that the resident was to be served pureed broccoli, the facility failed to provide the resident the vegetable of their choice by serving pureed carrots. Following the tray being checked for accuracy it was placed into the tray delivery cart for delivery. During an interview on 5/13/25, Resident R5 voiced a concern that she prefers not to receive gravy on her food products and always receives gravy on her food. 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 policies, observations and resident and staff interviews it was determined that the facility failed to provide the lunch meal on 5/13/25, in a timely manner which created an undignified dining experience for the residents of five of five nursing units (Roseview, Dogwood, Sunflower, Rehab Unit, and Cardinal Nursing units) Findings include: A review of facility policy Meal Times and Frequency dated 4/1/25 indicate that meals are served in a timely manner. During an interview on 5/13/15, at 11:30 am Resident R1 voiced a concern that her meal tray is always late and that her meal is not delivered until around 1:00 pm which is often a hour after the other residents on the unit are served there tray. A review of the facility's Meal Delivery Log revised on 1/4/24, indicated a lapse in time of approximately 50 minutes from when the first delivery cart arrives on the unit until the second cart arrives. During an observation of the Roseview Nursing unit on 5/13/25, at 11:50 am it was revealed…

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

Based on a review of facility documents, an audit conducted by the State Ombudsman Office and staff interviews, it was determined that the facility failed to notify the State Ombudsman Office of resident transfers and discharges for eight of eight months (a review period of from the facility's completed Medicare/Medicaid Recertification and State Licensure Survey completed on 6/21/24) (6/24, 7/24, 8/24, 9/24, 10/24, 11/24, 12/24, and 1/25) as required. Findings include: A request to review facility documents on 2/12/25, of the facility's compliance in notifying the State Ombudsman Office revealed the facility failed to provide documented evidence of notifying the State Ombudsman Office of residents transfers and discharges for the time period of 6/24, through 1/25. A review of an audit conducted 2/3/25, by the State Ombudsman Office revealed that the facility failed to notify the State Ombudsman Office of resident transfers and discharges. During an interview on 2/12/25, at 11:55 am the Director of Nursing confirmed that the facility failed to report resident transfers and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical record, and staff interview, it was determined that the facility staff failed to provide medications and treatments as ordered by the physician for two of five residents (Resident R1 and Resident R2). Findings include: Review of facility policy Medication Administration/Disposition dated 4/1/24, indicated medications shall be administered in a safe and timely manner, and as prescribed. Medications, both prescription and non-prescription, shall be administered under the orders of the attending physician, or the physician's designee. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR (Medication Administration Record) may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Topical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for two of three residents (Residents R1 and R2). Findings include: Review of facility policy Enteral Nutrition Therapy - General dated April 2024, indicated the facility will provide adequate nutritional support for the resident who is fed by enteral (the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) means. Licensed nurse will administer the tube feeding formula per physician's orders. In the event that a resident does not receive the prescribed amount of enteral feeding (milliliters - mL) per shift, the licensed nurse would notify the physician for further guidance. Review of facility policy Medication Administration/Disposition dated 4/1/24, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R1). Findings include: Review of facility policy Medication Administration/Disposition dated 4/1/24, indicated medications shall be administered in a safe and timely manner, and as prescribed. Medications, both prescription and non-prescription, shall be administered under the orders of the attending physician, or the physician's designee. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR (Medication Administration Record) may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility failed to maintain resident dignity for two of two residents (Resident R6 and R45). Findings include: Review of facility policy Dignity and Respect dated 4/1/24, indicated each resident shall be treated with dignity and respect at all times. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice, and protect resident privacy during treatment procedures. Review of the admission record indicated Resident R6 admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS- a periodic assessment of care needs) dated 4/2/24, indicated the diagnoses of traumatic brain injury (brain dysfunction caused by an outside force. Usually, a violent blow to the head), scoliosis (a sideways curvature of the spine), and high blood pressure. Observation on 6/20/24, at 8:28 a.m. outside vendor phlebotomist asked Nurse Aide (NA) Employee E15 where Resident R6 was, as she 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 facility policy, observations, resident council group interview, and staff interviews, it was determined that the facility failed to maintain a clean, safe, homelike environment for one of four residents (Resident R21). Findings include: The facility Resident Rights policy dated 4/1/24, indicated it is the facility policy to provide a safe, and home-like environment. Review of the admission record indicated Resident R21 was admitted to the facility on [DATE]. Review of Resident R21's MDS dated [DATE], indicated the diagnosis of anemia (low iron in the blood), hypertension (high blood pressure), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R21's physician orders did not include oxygen. During an observation on 6/17/24, at 9:47 a.m. Resident R21's room an oxygen tank, was in the corner of the room next to the bed and another oxygen tank was noted to be on the back of a wheelchair placed next to the bed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical records, incident reports, employee statements and staff interview, it was determined that the facility failed to ensure that residents were free from neglect by not providing the necessary services, which resulted in skin tears for two of five residents (Resident R31 and R50). Findings include: Review of the facility policy Abuse Policy - Prevention and Management dated 4/1/24, indicated the facility prohibits the mistreatment, neglect, and abuse of residents by anyone including staff, family, friends, visitors, etc. Deprivation of goods and/or services that are necessary to attain or maintain physical, mental, and psychosocial well-being is a definition of abuse. Review of the facility policy ADL Care- Resident Transfers- Mechanical Lifts dated 4/1/24, indicated a mechanical lift (a machine that moves residents from point A to point B) is used by trained staff for lifting/transferring residents when assessed as safe and appropriate. At least two nurse aides 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 review of facility policy, clinical records, and staff interview, it was determined that the facility failed to revise/update care plans for two of eight residents to accurately reflect the current status of the resident (Residents R108 and R115). Findings include: Review of facility policy Care Planning dated 4/1/24, indicated that care plan development, renewal, and revision will be based upon the results of the resident assessment. The interdisciplinary team will meet when a change in condition occurs to develop the comprehensive, resident centered plan of care for each resident. Review of the admission record indicated Resident R108 was admitted to the facility on [DATE]. Review of Resident R108's Minimum Data Set (MDS- a periodic assessment of care needs) dated 3/13/24, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), anxiety (intense, excessive, and persistent worry and fear about everyday situations), 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, clinical record review, and staff interviews, it was determined that the facility failed to provide weekly wound assessments for one of two sampled residents with non-pressure skin areas (Resident R46) and the facility failed to ensure that residents received treatment and care in accordance with standards of practice and physician orders regarding glucose devices for one of five residents (Resident R108). Findings Include: Review of the facility policy Accommodation of Needs dated 4/1/24, indicated the resident's individual needs and preferences shall be accommodated. The facility Assessment and management of wounds policy dated 1/2024 and last reviewed 4/1/24, indicated that the wound team will conduct weekly wound rounds on residents with full thickness loss wounds (arterial wounds, venous wounds, diabetic wounds and surgical wounds) in order to determine a appropriate treatments regiment, promote healing and assess wounds for progress. The wound care nurse will assess wounds weekly 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 and records, and staff interviews, it was determined that the facility failed to accurately monitor and assess for changes in skin condition for one of eight residents reviewed (Resident R179). Findings include: Review of the facility policy Risk Assessment and Prevention dated 4/1/24, indicated the facility will strive to ensure that a resident entering the facility without pressure ulcers/injuries does not develop pressure ulcers/injuries unless the resident's condition demonstrates unavoidable skin breakdown. Review of the admission record indicated Resident R179 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/30/24, indicated the diagnoses of respiratory failure (a serious condition that makes it difficult to breathe on your own), arthritis (swelling and tenderness in one or more joints, causing joint pain or stiffness), and Down Syndrome (a genetic chromosome 21 disorder causing developmental and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility documents, and resident and staff interviews, it was determined that the facility failed to follow appropriate interventions for one of three residents (Resident R39) who were at risk for falls. Findings include: Review of the facility policy Incident Reporting and Investigation of Accident Hazards, Supervision, Assistive Devices dated 4/1/24 indicates it is the policy of the facility to monitor and evaluate any adverse occurrence which in not consistent with the routine operation of the facility or care of a resident. Assistive Device refers to any item that is used by, or in the care of a resident to promote, supplement, or enhance the resident ' s function and/or safety. Review of the clinical record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's Minimum Data Set (MDS - periodic assessment of resident's care needs) dated 5/14/24, revealed diagnoses of heart failure (a progressive heart disease that affects pumping action…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, and staff interview, it was determined the facility failed to provide to provide appropriate care and services to residents receiving tube feedings for one of three residents reviewed (Residents R172). Findings include: The facility policy entitled Enteral Nutritional Therapy last reviewed 4/1/24, indicates if closed delivery system is used (ready to hang), licensed nurse will follow manufacturer recommendations for set ups, delivery, and maximum hang time. Licensed nurse will change equipment as recommended by manufacture, usually not to exceed forty-eight hours. Review of admission record indicated Resident R172 admitted to the facility on [DATE]. Review of Resident R172's Minimum Data Set (MDS- periodic assessment of care needs) dated 4/13/24, indicated diagnoses of anemia (low iron in the blood) atrial fibrillation (heart doesn't pump the way it should) and hypertension (high blood pressure). Section K- Swallowing/Nutritional Status indicated the resident 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 facility policies and clinical records, observations, and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent for one of three residents (Resident 144). Findings include: The observations listed below revealed two medication errors out of 28 opportunities resulting in a medication error rate of 7.14 percent. Review of the facility policy Medication Administration/Disposition dated 4/1/24, indicated medications shall be administered in a safe and timely manner, and as prescribed. Review of manufacturers guidelines for the Glargine Kwik Pen 100unit/ml (insulin injector that treats diabetes with long-acting insulin that decrease blood sugar) indicated that after attaching a new needle, to Prime your pen. Turn the dose select two units. Press and hold the dose button. Make sure a drop appears. Review of manufacturers guidelines for the Insulin Lispro (fast acting medication treats diabetes) Injection Kwik pen (injects insulin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, manufacturers recommendations, observation, and clinical record and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of five residents reviewed (Residents R144). Findings include: Review of facility policy, Insulin Pen Administration dated 4/1/24, indicated to select a dose of two units by turning the dosage selector, take off the outer needle cap, hold the pen with the needle facing upwards, and tap the insulin reservoir so that any air bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of the needle tip. A review of manufacturers guidelines for the Glargine Kwik Pen 100unit/ml (insulin injector that treats diabetes with long-acting insulin that decrease blood sugar) indicated that after attaching a new needle, to Prime your pen. Turn the dose select two units. Press and hold the dose button. Make sure a drop appears. A review of…

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

Based on review of facility policies, observations and staff interview it was determined that the facility failed to store all drugs and biologicals in a safe, secure and orderly manner for two of five units (Roseview and Sunflower). Findings include: Review of the facility policy Storage of Medications dated 4/1/24, indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendation or those of the supplier. Medication Room observation of Roseview Unit on 6/18/24, at 9:05 a.m. two vials of tuberculin solution were noted to be opened and without a date in the refrigerator. Interview on 6/18/24, at 9:05 a.m. Licensed Practical Nurse (LPN) Employee E8 confirmed the two vials were not dated when opened as required. Medication Room observation of Sunflower Unit on 6/18/24, at 9:45 a.m. one vial of tuberculin solution was opened and without a date in the refrigerator. Interview on 6/18/24, at 9:45 a.m. LPN Employee E11 confirmed the vial was not dated when opened as required. Interview on 6/18/24, at 9:50 a.m. LPN Employee E8 confirmed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility scheduled mealtimes, meal delivery observations, resident council group interviews, resident and staff interviews it was determined that the facility failed to ensure the provision of a nourishing (satisfying to the resident) evening snack when greater than 14 hours elapsed from the supper meal to breakfast the next day for residents including two of five residents sampled (Residents R29 and R104), and failed to ensure that meals were served at regularly scheduled times on two of five units meals were observed (Roseview and Cardinal). Findings include: Review of the facility policy Food and Nutritional Services dated 4/1/24, indicated the facility will serve at least three meals or their equivalent daily at scheduled times. There will not be more than a fourteen-hour span between the evening meal and breakfast. A review of facility's Meal Delivery Schedule revealed greater than 14 hours between dinner and breakfast: Sunflower Nursing Unit dinner meal at 4:30 p.m., and…

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

Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly monitor refrigerator temperatures on one of five nursing unit pantries (Roseview) which created the potential for food borne illness. Findings Include: Review of facility policy Pantry Refrigerators, dated 4/1/24, indicated pantry refrigerators will be monitored on a routine basis to ensure food safety. Refrigerator temperatures will be maintained at 36-46 degrees F. Freezer temps at 0 </= 10 degrees F (zero degrees or less than zero and up to 10 degrees F). Temperatures will be monitored and logged on a daily basis. A thermometer will be placed in the refrigerator and freezer. During an observation on the Roseview Nursing Unit Pantry on 6/20/24, at 12:00 p.m., revealed that the freezer was missing a thermometer in order to document the temperature. Further observation revealed a Temperature Log for Refrigerator and Freezer, dated June 2024, was missing recorded freezer temperatures from 6/1/24, through 6/20/24. During an interview on 6/20/24, at 12:03…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical record and staff interviews, it was determined that the facility failed to maintain hospice records for one out of three resident Records (Resident R159). Findings include: The facility Hospice policy dated 4/1/24, indicated that the facility will participate in hospice care as an approach for terminally ill residents. The facility must ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility. Review of Resident R159's admission record indicated she was admitted on [DATE]. Review of Resident R159's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 4/23/24, indicated she had diagnoses that included Alzheimer's disease (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), chronic kidney disease (a loss of kidney function…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for two of eleven residents (Residents R21 and R144) failed to prevent cross contamination during a dressing change for one of three residents (Resident R21) and failed to provide a safe and sanitary environment to help prevent the potential for cross contamination for one of five medication rooms (Dogwood Medication Room) Findings include: Review of the facility policy Transmission Based Precautions dated 4/1/24, indicated enhanced barrier precautions (EBP) are in place for residents with an infection or colonization of a multi-drug resistant organism (MDRO), wounds and/or indwelling medical devices, such as an indwelling catheter, trach/vent, central line, and feeding tube. Gowns and gloves are to be on before entering residents' rooms and used when providing high contact care with a resident who is in EBP. Review of facility policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop an individualized care plan to address the resident's specific nutritional concerns and preferences for three of seven (Resident R29, R104, and R192) records reviewed. Findings include: Review of facility policy Care Planning dated 4/1/24, indicated that care plan development, renewal, and revision will be based upon the results of the resident assessment. The interdisciplinary team will meet when a change in condition occurs to develop the comprehensive, resident centered plan of care for each resident. Review of the admission record indicated Resident R29 was admitted to the facility on [DATE]. Review of Resident R29's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/8/24, indicated the diagnoses of myocardial infarction, COPD (Chronic Obstructive Pulmonary Disease - preventable and treatable disease that is characterized by persistent respiratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement for two of two residents (Resident R1, and Resident R2). Findings include: Review of facility policy Elopement Prevention and Management last reviewed August 2023, indicated that the facility will strive to identify residents at risk for unsafe wandering and exit seeking behavior and to develop individualized prevention and management interventions based on Exit Seeking/Elopement Evaluation. Elopement is identified as when a resident leaves the premises or a safe area without the facility's knowledge and supervision. Review of facility policy Elopement- Facility Practices, last reviewed August 2023 indicated that the facility will assess the security of potential internal environmental risk factors including elevators, exit doors, screens, stairwells, and windows. Also, maintain door…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records and staff interview, it was determined that the facility failed to notify the resident's responsible party of change in condition for one of eight residents (Resident R1). Findings include: Review of the clinical face sheet indicated that Resident R1 was admitted to the facility 1/17/23, with diagnoses that included malignant neoplasm of the brain, bone and lung, type 2 diabetes mellitus and anxiety. Review of Resident R1 annual MDS assessment (MDS-Minimum Data Set Assessment. Periodic assessment of resident care needs) dated 12/20/23, indicated that the resident diagnoses were current. Review of Resident R1 medical records indicated that the resident's son was the Power of Attorney (POA). Review of Resident R1 nurse progress dated 1/15/2024 indicated Wound care RN called and spoke with residents daughter r/t bilateral upper thigh wounds being resolved and informed her of the current treatment plan. Review of Resident R1 nurse progress dated 2/1/2024 indicated that a message wound update given to daughter r/t current and new pressure wounds. Review of…

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

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to implement infection prevention and control monitoring policies for one of three residents (Resident R1). Review of facility policy Transmission Based Precautions 4/28/2023, indicated transmission-based precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. When transmission-based precautions are implemented the infection preventionist or designee shall post the appropriate notice on the room entrance door so that all personnel will be aware of precautions or be aware that they must see nurse to obtain additional information about the situation before entering the room. The facility will implement a system to alert staff to the type of precautions resident requires. Review of the Facility's system for identification of contact precautions for staff and visitors. Place signage that includes instructions for the identification of contact precautions for staff and visitors. Place signage that includes…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of 40 residents reviewed (Resident 22). This deficiency was cited as past non-compliance. Findings included: The facility's policy regarding medication administration, dated April 28, 2023, revealed that medications should be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The individual administering the medication must check the label three times to verify the right resident, right medication, right dose, right time, and right method of administration before giving the medication. If a drug is withheld, refused, or given at a time other than the…

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

Based on observations, resident, family and staff interviews it was determined that the facility failed to provide residents with the opportunity to file grievances, file grievances anonymously, and failed to ensure grievances were addressed by the facility and that all grievances were processed through the facility system and that the facility policy met the regulation. Findings include: Review of facility policy Grievances, dated 4/28/23, indicated the following: Our facility will assist residents, there representatives, family members or resident advocates in filing a grievance/concern form or completing a review on the customer service kiosk when concerns are expressed, which may not be able to be handled immediately by the facility staff, requires further investigation or requires consultation with other facility staff, the attending physicians or outside service providers. The policy also stated Grievance/concern forms may be submitted orally or in writing to any facility staff member or Anonymously Staff receiving the concern will immediately report the issue to the Unit…

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

Based on review of facility policy, personnel records and staff interview it was determined that the facility failed to provide nursing staff annual performance evaluations based on the date of hire for five of five nurse aides (NA Employee E4, E5, E6, E7, and E8) Findings include: During an interview on 8/25/23, at 10:43 a.m. the Regional Nurse Consultant Employee E17 confirmed that the most recent performance reviews on file were from the year 2020. During an interview on 8/25/23, at 2:30 p.m. the Nursing Home Administrator confirmed the facility failed to provide nursing staff annual performance evaluations based on the date of hire for five of five nurse aides. 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development 28 Pa Code: 201.14 (a) Responsibility of licensee

Based on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility. Findings include: A review of facility policy General Kitchen Cleaning Policy dated, 4/28/23, indicated that staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. During an observation made on 8/21/23, at 10:50 a.m., of the walk-in dairy cooler in the designated main kitchen of the facility revealed that cold air condenser fan covers and the ceiling immediately forward of these cooler fans had a build-up of dust, grime, and debris. During an interview made on 8/21/23, at 10:55 a.m., Food Service Director (FSD) Employee E18 confirmed that the walk-in cooler fan covers and the ceiling immediately forward of the cooler fans had a built-up of dust, grime, and debris as observed with surveyor. During an interview made on 8/21/23, at 10:56 a.m., Food Service Director (FSD)…

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

Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on abuse, neglect, and exploitation for four of ten staff members (Employees E9, E12, E14, and E15). Findings include: Review of the Facility Assessment dated 4/21/23, indicated staff training/education and competencies will be completed during general orientation upon hire, annually, and as needed. Educations listed included: -Communication -Resident Rights and Facility Responsibilities -Abuse, Neglect, and Exploitation -Infection Control Review of the Activity Employee E9's facility provided staff list indicated he was hired on 7/10/00. Review of Activity Employee E9's training record for 7/10/22, through 7/10/23, did not include training on abuse, neglect, and exploitation. Review of the Nurse Aide (NA) Employee E12's facility provided staff list indicated she was hired on 5/19/97. Review of NA Employee E12's training record for 5/19/22, through 5/19/23, did not include training on abuse, neglect, and exploitation. Review of NA Employee E14's facility provided…

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

Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on infection control for three of ten staff members (Employees E12, E14, and E15). Findings include: Review of the Facility Assessment dated 4/21/23, indicated staff training/education and competencies will be completed during general orientation upon hire, annually, and as needed. Educations listed included: -Communication -Resident Rights and Facility Responsibilities -Abuse, Neglect, and Exploitation -Infection Control Review of the Nurse Aide (NA) Employee E12's facility provided staff list indicated she was hired on 5/19/97. Review of NA Employee E12's training record for 5/19/22, through 5/19/23, did not include training on infection control. Review of NA Employee E14's facility provided staff list indicated she was hired on 6/8/18. Review of NA Employee E14's training record for 6/8/22, through 6/8/23, did not include training on infection control. Review of NA Employee E15's facility provided staff list indicated she was hired on 6/23/14. Review of NA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for three of five nurse aides (Employees E12, E14 and E15). Finding include: A review of the facility policy In-Service Training Records dated 4/28/23, indicated the facility will have an ongoing coordinated education program. Review of Nurse Aide (NA) Employees E12, E6, E14, and E15's education records with hire date greater than 12 months revealed the following: NA Employee E12 had a hire date of 5/19/97, with 9.25 hours in-service education between 5/19/22, and 5/19/23. NA Employee E14 had a hire date of 6/18/18, with 9.25 hours in-service education between 6/18/22 and 6/18/23. NA Employee E15 had a hire date of 6/23/14, with 0.00 hours in-service education between 6/23/22, and 6/23/23. During an interview on 8/25/23, at 1:33 p.m. the Registered Nurse Educator Employee E16 confirmed that the facility failed to provide 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 facility policy and procedure review, resident council interview, observations, resident interview, and staff interviews it was determined the facility failed to ensure the privacy of resident's mail for one of eight residents reviewed (Resident R19). Findings include: The facility Resident rights communication policy dated 6/2023, indicated that the facility must protect and facility resident right to communicate with individuals and entities and includes reasonable access to : a telephone, internet, postage and writing implements. The resident has the right to send and receive mail, letters, packages and other materials. Review of Resident R19's admission record indicated she was admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD-a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, resident family interview and staff interview it was determined that the facility failed to make certain a resident (Resident R102) was protected from abuse and neglect for one of four residents reviewed (Resident R102). The facility also failed to identify Resident R102's concerns as abuse and neglect to prevent future incidents. Findings include: The facility's policy Abuse Policy -Prevention and Management dated 4/28/23, indicated, The facility prohibits the mistreatment, neglect, abuse, of residents/patients and misappropriation/exploitation of resident patient/property by anyone including staff, family, friends, and visitors. The facility has designed and implemented process, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation/exploitation of property. The facility must provide a safe resident environment and protect residents from abuse. When a facility has…

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

Based on review of facility policy, personnel records and staff interview, it was determined that the facility failed to conduct an FBI background check on agency personnel prior to working on the nursing unit for one out of five personnel records (Agency nurse aide Employee E4). Findings include: The facility Abuse policy: prevention and management policy dated 4/28/23, indicated that the facility prohibits the mistreatment, neglect and abuse of residents and misappropriation of resident property. The facility has designated processes which strive to ensure the prevention and reporting of suspected allege resident abuse. All potential employees will be screened for a history of abuse, neglect or mistreating residents during the hiring process. Screening consist of the following: inquiries to the State licensing authority, criminal background checks, and fingerprinting as required by law. Review of Agency Nurse Aide Employee E4's personnel record indicated she was hired to the facility on 7/21/23. Review of Agency Nurse Aide Employee E4's personnel record driver's license…

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

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to revise/update care plans for two of nine residents to accurately reflect the current status of the resident (Resident R109 and R187). Findings include: A review of facility policy Care Planning dated 4/28/23, indicated that care plan development, renewal, and revision will be based upon the results of the resident assessment. The interdisciplinary team will meet when a change in condition occurs to develop the comprehensive, resident centered plan of care for each resident. Review of the admission record indicated that Resident R109 was admitted to the facility 5/5/20, with diagnoses that included cerebral infarction (a type of stroke caused by impaired blood flow to the brain, resulting in an area necrotic tissue), diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and peripheral vascular disease (systemic disorder of narrowed peripheral blood vessels resulting from a buildup of plaque). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents were provided appropriate treatment and services to maintain bowel function for one of five residents (Resident R124). Findings include: Review of the facility policy, Bowel Protocol, dated 1/28/23, indicated that resident ' s bowel movements will be monitored daily by 11-7 supervisor, residents who have not had a bowel movement for two days are identified and considered to be at risk for constipation, nursing staff will encourage the resident to increase the ingestion of fluids, and residents will continue to be monitored by nursing for bowel movements following each step of the protocol, and document results as appropriate. Review of the addendum to the Bowel Protocol policy, Constipation Management indicated that constipation is three or more days without defecation. This document further stated that a contributing factor for constipation is the use of opioids.…

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

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly and securely store medications in one out of eight medications carts (Southeast/B-hall medication cart). Findings include: The facility Medication storage policy dated 4/28/23, indicated that medications and biologicals are stored safely, securely and properly, following manufacturer's recommendation. During observations on 8/22/23, at 12:09 p.m. observations of Dogwood unit medication cart named Southeast /B-hall medication cart with Licensed Practical Nurse (LPN) Employee E1, observations found two insulin pens, open and without an open date belonging to Resident R101. During an interview on 8/22/23, at 12:09 p.m. with LPN Employee E1 stated that the insulin pens were open and without an open date. During an interview on 8/25/23, at 2:08 p.m. the Assistant Director of Nursing Employee E2 confirmed that the facility failed to properly and securely store medications in the Southeast/B-hall medication cart as required. 28 Pa. Code: 211.9(a)(1)(h)(k)(l)(1)…

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