Camp Hill Skilled Nursing And Rehabilitation Ctr

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to ensure Medication Regimen Reviews were responded to by the attending physician or prescriber for one of five residents reviewed (Resident 4). Findings include: Review of facility policy, titled Medication Regimen Review and Reporting, revised January 2024, revealed, For recommendations that do not require physician intervention, the director of nursing or licensed designee will address the recommendations. Review of Resident 4's clinical record revealed diagnoses that included major depressive disorder (a serious, common mood disorder characterized by persistent sadness, loss of interest, and fatigue, lasting at least two weeks and impairing daily life) and dementia (a general term for severe mental function loss). Review of Resident 's medical record revealed a recommendation made on September 9, 2025, by the consultant pharmacist to add an parameters for Resident 4's PRN (as needed) pain medication. Further review of the record failed to reveal that the…

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

Based on observation, facility policy review, medical record review, and staff interviews, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of three residents reviewed (Resident 8).Findings include:Review of facility policy, NSG213 Enteral Management, revised July 22, 2025, failed to reveal any expectation that tube feeding solution would be labeled with the name of the solution and date/time that the tube feeding was initiated.Review of Resident 8's clinical record revealed diagnoses that included Acute kidney failure (a sudden and often temporary loss of kidney function) and diabetes (a disease that affects how the body manages blood sugar).Observation of Resident on October 6, 2025, at 1:45 PM, revealed a bottle of beige liquid hanging at Resident 8's bedside in an open tube feeding set-up (bottle and tubing used to administer tube feedings). The bottle was not labeled with what tube feeding was contained inside, the initials of the individual who hung it, or the date and time that it was hung for…

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

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for one of eight residents on transmission-based precautions reviewed (Residents 7).Findings Include:Review of facility policy, IC308 Enhanced Barrier Precautions (EBP), revised December 6, 2024, revealed that residents with a wound or indwelling medical device will be placed on EBP if they do not meet criteria to require contact precautions.Review of Resident 7's clinical record revealed diagnoses that included pressure ulcer of left heel (an injury to the skin and/or underlying tissue caused by prolonged pressure) and chronic kidney disease (gradual loss of kidney function).Review of Resident 7's care plan revealed a current care plan for skin breakdown related to impaired mobility, Pressure ulcer left heel stage 2, with a revision date of August 20, 2025.Observation of Resident 7's room on October 6, 2025, at 12:30 PM, revealed no sign on Resident 7's 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 facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal hygiene for three of 24 residents reviewed (Residents 20, 35, and 101). Findings include: Review of facility policy, titled NSG200 Activities of Daily Living (ADLs) [Activities of daily living or ADLs are routine tasks that each of us must perform every day to care for our bodies and ourselves independently] dated June 1, 1996, with a revision date of May 1, 2023, and a last review date of October 15, 2024, revealed 1. Patients are assessed upon admission, quarterly, and with any significant change to identify their status in all areas of ADL's and 4.2 A patient who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident 20's clinical record revealed diagnoses that…

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

Based on observations, clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure treatment and services, consistent with professional standards, to promote healing and prevent infection for two of six residents reviewed for pressure ulcers (Residents 16 and 325). Findings include: Review of facility policy, titled NSG236 Skin Integrity and Wound Management, with a last reviewed and revised date of October 15, 2024, revealed 6. The licensed nurse will: 6.5 Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with any unanticipated decline in wounds. Review of Resident 16's clinical record revealed diagnoses that included chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats causing the heart to be unable to pump an adequate amount of blood to the body), chronic respiratory failure (long term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body), and chronic…

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

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for three of five residents reviewed for limited range of motion (Residents 35, 40, and 50). Findings include: Review of facility policy, titled Restorative Nursing Guidelines, dated April 1, 2024, read, in part, Restorative nursing services (RNP) refer to interventions that promote the patient's ability to adapt & adjust to living as independently & safety as possible. It includes interventions that promote the resident's ability to attain & maintain their maximum functional potential. RNP's include, but are not limited to: Active Range of Motion (AROM) & Passive Range of Motion (PROM). Developing a RNP includes patient need identification, program design, documentation & monitoring outcomes. The program must include documentation of the number of minutes spent per restorative session. Document daily restorative nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, observations, and staff interviews, it was determined that the facility failed to store food and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen and one of three nourishment areas. Findings include: Based on facility policy, titled Food and Nutrition Services 'Use By' Dating Guidelines, last reviewed October 15, 2024, read, in part, Guidelines apply regardless of storage location (e.g. kitchen, pantries, etc.). Thickened liquids- 'use by' date seven days after opening. Frozen shakes 'use by' date of fourteen days once thawed- use labels for individual items when removed from the carton. Based on facility policy, titled Food Brought in for Patients/Residents, last reviewed October 15, 2024, read, in part, Food brought to residents by family or visitors will be handled and stored in a safe and sanitary manner. Food items that require refrigeration must be labeled with a resident's name and date the food was brought in. Food will be held in refrigerator for up to three days following date…

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

Based on review of clinical record review, review of select facility documentation, and staff interview, it was determined that the facility failed to provide the required notices to the resident or their representatives following the end of their Medicare coverage for two of three residents reviewed for beneficiary notices (Residents 28 and 108). Findings include: A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form completed by the facility revealed that Medicare Part A coverage for Resident 28 started on December 9, 2024, and that her last covered day was January 6, 2025. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the Resident's benefit days were not exhausted. Further review of the form indicated that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF-ABN - a notice given to Medicare beneficiaries to convey that Medicare is not likely to provide coverage for a skilled service) was issued telephonically. Review of Resident 28's clinical record revealed that she remained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 exercise reasonable care for the protection of the resident's property from loss or theft for two of three discharged residents reviewed (Residents 105 and 106). Findings include: Review of Resident 105's clinical record revealed she was admitted to the facility on [DATE], and discharged from the facility to the hospital on November 12, 2024. Further review of the closed clinical record revealed no documented inventory of personal effects or accounting for Resident 105's personal effects following discharge. Review of Resident 106's clinical record revealed he was admitted to the facility on [DATE], and passed away at the facility on December 25, 2024. Further review of the closed clinical record revealed no documented inventory of personal effects, or accounting for Resident 106's personal effects following discharge. During an interview with the Director of Nursing on January 16, 2025, at 12:30 PM, she 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 facility policy review, review of incident investigation documentation, and staff interview, it was determined that the facility failed to report the results of an abuse investigation within the specified timeframes for one of one abuse incidents reviewed. Findings include: Review of facility policy, Abuse Prohibition, revised October 24, 2022, revealed, The Administrator or designee will report findings of all completed investigations within five (5) working days to the Department of Health using the state on-line reporting system or state-approved forms. Review of state form, PB-22 Report Form For Investigation of Alleged Abuse, Neglect, Misappropriation of Property, completed by the facility, revealed that an alleged incident of neglect occurred on September 24, 2024. Further review of the form revealed that the facility became aware of the incident and began an abuse investigation on September 25, 2024. The investigation was concluded on September 26, 2024. Review of the form indicated that it was not completed and submitted to the Department of Health until October 7,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 24 residents reviewed (Residents 8 and 36). Findings include: Review of Resident 8's clinical record revealed diagnoses that included congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), chronic kidney disease (a condition characterized by a gradual loss of kidney function), and muscle weakness. Review of Resident 8's Annual MDS (Minimum Data Set- assessment tool utilized to identify residents' physical, mental, and psychosocial needs) with ARD (assessment reference date- last day of the assessment period) of December 4, 2024, revealed under Section N. Medications, Resident 8 was marked yes to indicate he received an anticoagulant. Review of Resident 8's Medicare 5 Day MDS with ARD of December 4, 2024, revealed under Section N, Resident 8 was marked yes to indicate he received an anticoagulant. Review of Resident 8's clinical record failed to…

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

Based on clinical record review and staff interview, it was determined that the facility failed to develop comprehensive care plans for two of 27 resident records reviewed (Residents 29 and 47). Findings Include: Review of Resident 29's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and anxiety disorder (mental health conditions that involve persistent and excessive feelings of fear or worry). Review of Resident 29's current physician orders revealed an order for Buspirone hydrochloride (HCL) tablet 15 milligram (MG) - give one tablet by mouth two times a day for anxiety, with an original active date of July 19, 2024. Review of Resident 29's current physician orders revealed an order for Duloxetine HCL capsule delayed release particles 60 MG -give one capsule by mouth one time a day for depression, with an original active date of July 20, 2024. Review of Resident 29's current physician orders revealed an order for Enoxaparin Sodium Injection Solution Prefilled syringe 40 MG/0.4 milliliter - inject 40 MG intramuscularly every 24 hours for…

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

Based on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the residents right to participate in the care planning process for one of 24 residents reviewed (Resident 19), and failed to review and revise the resident plan of care for one of 24 residents reviewed (Resident 50). Findings include: Review of facility policy, titled OPS416 Person-Centered Care Plan, dated November 28, 2016, with a revision date of October 24, 2022, and a last review date of October 15, 2024, revealed 7. Care plans will be: 7.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals; and 9. The Center has the responsibility to assist patients to participate by: 9.3 Facilitating the inclusion of the patient/ resident representative(s) to attend. Review of Resident 19's clinical record revealed diagnoses that included chronic pain, hypertension…

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

Based on review of the clinical record and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 24 residents reviewed (Residents 71 and 88). Findings include: Review of Resident 71's clinical record revealed diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder) and hypertension (elevated blood pressure). Review of Resident 71's December 2024 MAR (Medication Administration Record) revealed a physician's order for Blood Glucose before meals - notify MD (Medical Director) if blood sugar less than 80 or blood sugar greater than 250 before meals for Glucose monitoring, with a start date of December 26, 2024. Review of Resident 71's December 2024 MAR revealed the following: On December 26, 2024, at 4:00 PM, Resident 71's blood sugar was 286. On December 31, 2024, at 6:00 AM, Resident 71's blood sugar was 316. On December 31, 2024, at 11:00 AM, Resident 71's blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical record review, hospital record review, and staff interview, it was determined that the facility failed to ensure the physician provided orders for the resident's immediate care and needs for one of 24 residents reviewed (Resident 325). Findings include: Review of Resident 325's clinical record on January 13, 2025, revealed diagnoses that included stage two chronic kidney disease (decreased ability of kidneys to filter toxins from the blood), diabetes mellitus type II (decrease in the body's ability to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment), and a stage three pressure ulcer to the sacrum (wound of the skin that can extend to the deeper layers of the skin caused by pressure over a bony prominence). Review of Resident 325's clinical record revealed that Resident 325 was admitted to the facility from the hospital on January 7, 2025. Review of hospital documentation revealed that while Resident 325 was in the hospital, Resident 325 had a foley…

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

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain an accurate accounting of the final disposition of medications upon discharge for two of three closed records reviewed (Residents 105 and 107). Findings Include: Review of facility policy, Disposal of Medication Waste, revised July 1, 2024, revealed, Medications that cannot be returned to the pharmacy, discharged with the patient, or donated will be placed in medication disposal bins labeled .controlled substance waste. Review of facility policy, Collection Receptacles for Disposal of Medications, undated, revealed, When disposing of such controlled substances by transferring those substances into a collection receptacle, such disposal shall occur immediately, but no longer than three business days after the discontinuation of use by the resident/ultimate user. Discontinuation of use includes a permanent discontinuation of use as directed by the prescriber, as a result of the resident's transfer from the long-term care facility, or as a result 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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity was reviewed and acted upon timely for two of five residents reviewed for unnecessary medications (Residents 29 and 74). Findings include: Review of facility policy, titled Medication Regimen Review, last reviewed October 15, 2024, read, in part, Medication Regimen Review (MRR) is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report and resolve medication-related problems, medication errors, or other irregularities. The findings are communicated to the Director of Nursing (DON) or designee and the medical director. These findings are documented and filed with other consultant pharmacist recommendations in the resident's chart. Resident-specific MRR recommendations 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 observations, facility policy review, review of medication data sheets, and staff interviews, it was determined that the facility failed to discard expired medications in one of three medication carts (Arcadia); and failed to properly label drugs and biologics in one of three medication carts (3rd floor short hall cart). Findings include: Review of facility policy, titled Storage of Medications, with a last review date of October 15, 2024, revealed, 12. [in part] Note the date on the label for insulin vials and pens when first used; and 14. [in part] Outdated .medications are immediately removed from stock, disposed of according to procedures. Review of insulin degludec (a long-acting insulin used to manage diabetes) medication data sheet from Drugs.com revealed that this brand of insulin should be used or discarded within 56 days of opening. Review of insulin aspart (a fast-acting insulin used to lower blood sugar levels) medication data sheet from Drugs.com revealed that this brand of insulin should be used or discarded within 28 days of opening. Review of Medline Liquid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, observations, facility policy review, and staff interview, it was determined that the facility failed to implement infection control practices to help prevent the development and transmission of infectious diseases for one of one treatment cart observed (Third floor treatment cart). Findings include: Review of facility policy, titled Infection Prevention and Control Program Description, last reviewed October 15, 2024, revealed it stated, .Implementation of Control Measures and Precautions includes basics such as hand hygiene, Standard and Transmission Based Precautions, cleaning/disinfecting equipment and measures to protect persons [sic] from communicable diseases or infections. Review of Resident 325's clinical record on January 13, 2025, revealed diagnoses that included stage two chronic kidney disease (decreased ability of kidneys to filter toxins from the blood), diabetes mellitus type II (decrease in the body's ability to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment), and a stage three…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, laboratory result review, facility policy review, and resident and staff interviews, it was determined that the facility failed to ensure the facility's Antibiotic Stewardship Program was implemented for one of two residents reviewed for antibiotic use (Resident 98). Findings include: Review of facility policy, titled IC402 Antibiotic Stewardship, last revision date of December 16, 2024, revealed the facility policy stated, Centers will implement an Antibiotic Stewardship Program (ASP) as part of the facility's overall infection and control program . The policy's included purpose stated, To reduce inappropriate antibiotic use and prevent the development of antibiotic-resistant organisms. Review of the policy's Process section revealed the program included the following: 1. The Medical Director, [Director of Nursing], and Consultant Pharmacist serve as the leaders of the ASP and receive support from the Administrator and other governing officials of the Center. 1.1 The Medical director .Sets the standards for antibiotic prescribing practices for 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 facility policy review, observations, clinical record review, staff interviews, and facility documentation review, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for four of 12 residents reviewed (Residents 4, 9, 10, and 12). Findings include: Review of facility policy, titled Medication Administration Section 7.1 General Guidelines, dated January 2024, revealed Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices; 1. Medications are administered in accordance with written orders of the prescriber .14. medications are administered within 60 minutes of scheduled time. Observation of third floor on July 25, 2024, at 11:30 AM, revealed that Employee 1 (Licensed Practical Nurse [LPN]) and Employee 2 (LPN) were administering medications to residents. During an interview with Employee 1 on July 25, 2024, at 11:31 AM, Employee 1 indicated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 24 residents reviewed (Residents 25, 54, and 65). Findings include: Review of Resident 25's clinical record on February 5, 2024, at approximately 1:00 PM, revealed diagnoses that included diabetes type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and hypertension (elevated/high blood pressure). Review of Resident 25's Quarterly Minimum Data Set (MDS - standardized assessment tool utilized to identify a resident's physical, mental, and psychosocial needs), with an assessment reference date of December 17, 2023, revealed that section M - Skin Conditions, subsection M300 - Current Number of Pressure Ulcers/Injuries at Each Stage was coded to reflect Resident 25 had one stage II pressure ulcer (injury of the skin that is caused by…

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

Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for three of 25 residents reviewed (Residents 42, 55, and 73). Findings include: Review of Resident 42's clinical record revealed diagnoses that included dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and diabetes (a group of diseases that result in too much sugar in the blood [high blood glucose]). Review of Resident 42's progress notes from January 22, 2024, at 11:09 AM, revealed a progress note written by Employee 3 (Physician), that revealed Resident 42 had dementia and the plan of care was to, continue with supportive care. Review of Resident 42's MDS (Minimum Data Set evaluation), dated December 29, 2023, revealed in section I4800 that Resident 42 has an active diagnosis of Non-Alzheimer's dementia, meaning that the condition required and received treatment within the previous seven days. Review of Resident 42's care plan on February 5, 2024, failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 24 residents reviewed (Resident 51). Findings include: Review of Resident 51's clinical record revealed diagnoses that included end-stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis), dependence on renal dialysis (external filtering of the blood performed by a machine by removing the blood and replacing it), and adult failure to thrive (a past history of weight loss of more than five percent, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction). Review of Resident 51's physician orders revealed an order for daily weights, dated April 18, 2023. Review of Resident 51's weights in their electronic health record 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of one residents reviewed (Resident 51). Findings Include: Review of facility policy, titled NSG253 Dialysis: Hemodialysis (HD) - Communication and Documentation, with a last review date of January 17, 2024, indicated, in part, Center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis (HD) treatments received at a certified dialysis facility. 1. Prior to a patient leaving the Center for HD, a licensed nurse will complete the top portion of the Hemodialysis Communication Record or the state required form and send with the patient to his/her HD facility visit. 2. Following completion of the HD, the dialysis facility nurse should complete and return the form and return it or other communication to the Center with the patient. 3. Upon return of the patient…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, policy review, and staff interviews, it was determined that the facility failed to ensure that the clinical record accurately reflected the resident preference for code status for one of 24 residents reviewed (Resident 18). Findings include: Review of facility policy, titled Health Care Decision Making, last revised [DATE], revealed purpose - to provide patient the opportunity and knowledge necessary to make his/her health care decisions known and to assure that patients' wishes concerning health care decisions are communicated to all staff so that patients' rights will be honored and their wishes will be executed at the appropriate time. Review of Resident 18's clinical record revealed diagnoses that included dementia (progressive or persistent loss of intellectual functioning) and rhabdomyolysis (breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood). Further review of Resident 18's clinical record on February 6, 2024, at 10:04 AM,…

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

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 24 residents reviewed (Residents 51 and 65). Findings include: Review of facility policy, titled OPS416 Person-Centered Care Plan, dated November 28, 2016, with a last review date of January 17, 2024, revealed, in part, 7. Care plans will be: .7.2. Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. Review of Resident 51's clinical record revealed diagnoses that included end-stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis), peripheral vascular disease (disease of the vascular system that results in decreased blood flow to the extremities), and hypertension (high blood pressure). Review of Resident 51's care plan revealed a care plan focus for a right heel pressure ulcer, with a last…

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