Gardens At Camp Hill, The

Based on policy review, clinical record review, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to provide care and services in accordance with professional standards of practice to ensure the resident's highest level of well-being for one of four residents reviewed (Resident 11). Findings include: Review of facility policy, Medication Administration, undated, revealed, Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label .Residents are identified before medication is administered. Methods of identification include: a. Checking identification band, b. Checking photograph attached to medical record, c. If necessary, verifying resident identification with other facility personnel .Medications supplied for one resident are never administered to another resident. Review of Resident 11's clinical record revealed diagnoses that included Cauda Equina Syndrome (occurs when the bundle of the nerves at the lower end of the spinal cord 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 policy review, document review, and staff interviews, it was determined that the facility failed to protect the resident's right to be free from physical abuse by Employee 7 for one of six residents reviewed (Resident 4). Findings Include: A review of the facility's policy, titled Preventing Resident Abuse, revised November 28, 2016, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment that results in physical harm, pain or mental anguish. A review of Resident 4's clinical record revealed diagnoses that included schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder. Symptoms may occur at the same time or at different times. Cycles of severe symptoms are often followed by periods of improvement. Symptoms may include delusions, hallucinations, depressed episodes, and manic periods of high energy) and a history of a traumatic brain injury (Brain dysfunction caused by an outside force,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review and staff interviews, it was determined that the facility failed to ensure sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing related services to assure resident safety and care for residents with mental and psychosocial disorders and a history of trauma to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of six residents reviewed (Resident 4). Findings Include: Review of the facility's Registered Nurse Job Description dated December 11, 2023 and signed by Employee 7 read, Purpose of Your Job Description- Supervise day to day nursing activities of the facility. Such supervision must be in accordance with federal, state and local standard guidelines, and regulations that govern the facility, and may be required by the Director of Nursing Services, to ensure the highest quality care is maintained at all times. Also, Interact/communicate with residents, staff 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, clinical record review, observations, and staff interviews, it was determined that the facility failed to maintain a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases, and failed to ensure staff follow professional standards of infection control practices during medication administration for two of five residents observed for medication administration (Residents 34 and 78). Findings include: Facility policy, titled Infection Control Prevention, Control and Antibiotic Stewardship, last reviewed July 25, 2024, read, in part, E. Measures for the Detection, Control and Prevention of HealthCare Acquired Infections. Detection of HealthCare Acquired Infections (HCAI) is accomplished through a facility based ongoing system of surveillance. All infections are identified and reported to the facility Infection Control Preventionist of designee . A Line Listing of residents with infections is maintained and tracked for trending and outbreak potential. Follow up review of lab data is compared. A…

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

Based on clinical record review, facility documentation review, and resident and staff interviews, it was determined that the facility failed to ensure one of one residents reviewed were provided the right to self-determination in regard to a room change (Resident 10). Findings include: Review of Resident 10's clinical record revealed diagnoses that included anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and major depressive disorder (a mental health disorder characterized by persistent low mood, decreased involvement in pleasurable activities, sleep and appetite pattern disruptions). During an interview with Resident 10 on July 29, 2024, at 2:02 PM, Resident 10 indicated that the Resident had requested a room change that had not been accommodated. Resident 10 indicated that the he had requested the room change because their roommate yells out frequently. Review of Resident 10's clinical record revealed a social services note dated April 5, 2024, at 11:37 AM, 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 a review of resident council meeting minutes, policy review, and resident and staff interviews, it was determined that the facility failed to have evidence to support that resident council grievances were acted upon. Findings include: Review of the facility's policy, titled Activities/Recreation Administration, revealed that the Activities/Recreation department shall maintain monthly resident council minutes and communicates appropriate information to facility staff. Resident Council meeting minutes for April 2024, May 2024, June 2024, and July 2024 revealed that there were no concerns expressed during the meetings. During an interview on July 30, 2024, at 10:00 AM, with a group of five residents, revealed that the Residents have brought up multiple concerns at the Resident Council meeting and have been given no resolution regarding their concerns. The Residents stated that they go over the same concerns during every Resident Council meeting and do not review old business at the meetings. In the past four months, they have reported complaints about cold food, long waits 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 provide residents access to grievance forms in a manner that honors the right to file grievances anonymously for one of two resident areas observed (first floor), as well as five of five residents in attendance at the group interview (Residents 3, 17, 46, 71, and 87); and failed to make prompt efforts to resolve a grievance for one of six residents reviewed (Resident 85). Findings include: Review of the facility policy, titled Grievance Policy, with a review date of July 25, 2024, revealed that The facility will make information on how to file a grievance or complaint available to the resident by notifying the resident individually or with prominent postings throughout the facility to include: the right to file a grievance anonymously. Multiple observations from July 29, 2024, to August 1, 2024, in the facility failed to reveal that grievance forms were readily available to residents or resident representatives (first floor). Review of Resident…

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

Based on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident's comprehensive plan of care accurately reflected the needs of the resident for three of 21 residents reviewed (Residents 20, 60, and 72). Findings include: Review of the facility policy, titled Care Plans, Comprehensive Person-Centered, with a review date of July 25, 2024, revealed Policy Statement. A comprehensive, person-centered care plan that includes objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and for each resident . 8. The comprehensive, person-center care plan will: b. Describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of Resident 20's clinical record revealed diagnoses that included type two diabetes mellitus (condition where the 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.

Based on facility policy review, record review, and resident and staff interviews, it was determined that the facility failed to review and revise the resident plan of care and ensure the residents right to participate in the care planning process for seven of 27 residents reviewed (Resident 3, 34, 56, 58, 71, 73, and 81). Findings include: Review of facility policy, titled Care Planning - Interdisciplinary Team, last revised September 2013, read, in part, The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. Review of Resident 3's clinical record revealed diagnoses that included hypertension (high blood pressure) and dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life). During an interview with Resident 3 on July 30, 2024, at approximately 10:30 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 resident representative and staff interviews, it was determined that the facility failed to ensure each resident received treatment in accordance with professional standards of practice for two of 21 residents reviewed (Residents 25 and 85). Findings Include: Facility policy, titled Pacemaker, Care of a Resident, with a last reviewed July 25, 2024, read, in part, Monitoring. 3. The pacemaker battery will be monitored remotely through the telephone or an internet connection. 4. The resident will have an EKG (electrocardiogram) annually, or as ordered, to monitor for changes in the heart's electrical activity. 5. Make sure the resident has a medical identification card that indicates he or she has a pacemaker. The medical record must contain this information as well. Documentation. 1. For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: a. The name, address, and telephone number of the cardiologist; b.Type of pacemaker; c. Type of leads; d.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 act upon the licensed pharmacist's report of a medication irregularity for one of five residents reviewed for unnecessary medications (Resident 29). Findings include: Review of facility policy, titled Medication Regimen Review, last reviewed July 25, 2024, read, in part The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. Recommendations are acted upon and documented by the facility staff and or the prescriber. The director of nursing of designated licensed nurse address and document recommendations that do not require a physician intervention, e.g., monitor blood pressure. Review of Resident 29's clinical record revealed diagnoses that included hypotension (low blood pressure), dysphagia (difficulty swallowing), and atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating). Review of Resident 29's physician orders revealed the following orders: Midodrine HCl Tablet 5 MG…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen. Findings include: Review of facility policy, titled Chapter 3 Food, not dated, read, in part, Packaged food shall be labeled as specified in law including food labeling, labeling marking devices, and containers. Food shall be protected from cross contamination. During preparation, unpackaged food shall be protected from environmental sources of contamination. A test kit or other device that accurately measures the concentration of sanitizing solutions shall be provided. Observation of the walk-in freezer on July 29, 2024, at 9:38 AM, revealed a bag of mixed vegetables not dated; one bag of corn not dated; one bag of peas not dated; two angel food cakes not dated; and one frozen beverage cup as well as one frozen shake from an outside source. During an interview with Employee 5 (Dietary Manager) on July 29, 2024, at 9:39 AM, he revealed 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 review of the sign-in sheets for the facility's Quality Assurance (QA) Committee and staff interview, it was determined that the required members failed to attend a meeting at least quarterly for two of three quarters over the past year. Findings include: Review of all available documentation submitted by the facility revealed no evidence that the Nursing Home Administrator (NHA) and the facility Infection Control Preventionist attended a meeting during the quarter of October 2023, November 2023, and December 2023. Review of all available documentation submitted by the facility revealed no evidence that the facility Infection Control Preventionist attended a meeting during the quarter of April 2024, May 2024, and June 2024. During an interview with the NHA and the Director of Nursing (DON) on August 1, 2024, at approximately 9:28 AM, the NHA indicated that the facility QA committee meets monthly. He confirmed that the aforementioned members did not attend at least one meeting in the last quarter of 2023 or the second quarter of 2024. He further indicated that he would…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's infection prevention and control policy and staff interview, it was determined that the facility failed to maintain an antibiotic stewardship program that includes a system to effectively monitor antibiotic usage. Findings include: Facility policy, titled Infection Control Prevention, Control and Antibiotic Stewardship, last reviewed July 25, 2024, read, in part, A. Mission and Goals. The infection Prevention and Control Plan is a comprehensive process that addresses preventing, identifying, reporting, investigating, and controlling infections and communicable diseases and monitoring judicious use of antibiotic to individuals .the goals of the program are to: 3. Optimize the use of antibiotics to meet resident and community specific needs .6. Facilitate compliance with state and federal regulations relating to infection control and antibiotic stewardship. B. Scope 6. Core Elements of Antibiotic Stewardship Action: Formal review procedure for the appropriateness of any antibiotics prescribed by the Infection Preventionist on a regular basis when…

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

Based on review of regulations, facility policy review, and staff interviews, it was determined that the facility failed to have an Infection Preventionist (IP) that worked at least part time at the facility. Findings Include: The Centers for Medicare and Medicaid Services regulation §483.80(b)(3) stated, The facility must designate one or more individual(s) as the infection Preventionist(s) (IP)(s) who are responsible for the facility ' s IPCP. The IP must: Work at least part-time at the facility. The IP must physically work onsite in the facility. He/she cannot be an off-site consultant or perform the IP work at a separate location such as a corporate office or affiliated short term acute care facility. Review of facility policy, titled Infection Control Prevention, Control and Antibiotic Stewardship, last reviewed July 25, 2024, revealed The facility designates one or more individual(s) as the infection Preventionist(s)(IPs) who are responsible for the facility IPCP. The IP works at least part-time at the facility. During an interview with the Director of Nursing, 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 review of personnel training records and staff interviews, it was determined that the facility failed to ensure each nurse aide was provided with the required in-service training consisting of no less than 12 hours per year for five of five nurse aide employee records reviewed (Employees 6, 7, 8, 9, and 10), and failed to provide annual training that included resident abuse prevention for one of five nurse aide employee records reviewed (Employee 6). Findings Include: Review of personnel information revealed Employee 6's hire date was November 18, 1992; Employee 7's hire date was October 16, 2000; Employee 8's hire date was November 15, 2004; Employee 9's hire date was October 15, 2007; and Employee 10's hire date was December 19, 2022. Review of facility training records failed to reveal that the aforementioned Employees completed 12 hours of required annual training in the past 12 months. Further review of facility training records failed to reveal evidence that abuse prevention training was completed by Employee 6 within the past 12 months. During an interview with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to include a resident in the development of their baseline care plan to establish the initial goals of the resident, and failed to provide the resident or their representative a written summary of their baseline care plan for two of two residents reviewed (Residents 6 and 30). Findings include: Review of facility policy, titled Care Plans- Baseline, with a revised date of December 2016, and a last review date of July 25, 2024, revealed 4. The facility must provide the resident and the representative, if applicable, with a written summary of the baseline care plan by completion of the of the comprehensive care plan. Review of facility policy, titled Care Planning - Interdisciplinary Team, last revised September 2013, read, in part, The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of 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 facility policy, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide services necessary to maintain adequate personal grooming of residents' dependent on staff for assistance with these activities of daily living for two of three residents reviewed (Residents 36 and 53). Findings Include: Review of facility policy, titled Activities of Daily Living (ADLs), Supporting, with a review date of July 25, 2024, revealed Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care). Review of Resident 36's clinical record revealed diagnoses that included hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD-a common lung disease causing restricted airflow and breathing problems). During an interview with Resident 36 on July 29, 2024, at 10:15 AM, revealed 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 and staff interviews, it was determined that the facility failed to ensure that garbage and refuse was disposed of properly, and sanitary conditions were maintained in the garbage storage area for one of one dumpster observed. Findings include: Observation of the receiving area dumpster on July 29, 2024, at 9:25 AM, revealed there were two bags of garbage on the ground in front of the dumpster; one was open and garbage was spilled out onto the ground, and there were five bags of garbage piled up on the ground to the left of the dumpster. Employee 5 (Dietary Manager) opened the sliding door to the garbage receptacle and it was empty. Interview with Employee 5 on July 29, 2024, at 9:29 AM, revealed the trash was left there by housekeeping staff and it should not be on the ground. Observation on July 30, 2024, at 8:39 AM, 11:40 AM, and 1:52 PM, revealed the sliding door to the dumpster was open while not in use. Interview with the Nursing Home Administrator on July 31, 2024, at 11:09 AM, revealed it is his expectation that the dumpster sliding door should be kept…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, clinical record review, and staff interviews, it was determined that the facility failed to provide beverages for a resident in a form to meet the resident's individual need for one of four residents reviewed (Resident 1). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and chronic obstructive pulmonary disease (COPD- a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). Review of Resident 1's current physician orders revealed a diet order dated May 14, 2024, for a regular diet, mechanical soft texture, nectar consistency liquids. Review of Resident 1's current care plan revealed an intervention dated March 9, 2024, Ensure that all beverages offered comply with diet/fluid restrictions and consistency requirements; and an intervention, revised May 22, 2024, to provide diet as ordered: mechanical soft with nectar thick liquids. Review of facility grievance log revealed that on June 3, 2024,…

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

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to provide care and services regarding showering for one of five residents reviewed (Resident 2). Findings include: Review of facility policy, titled Activities of Daily Living (ADLs), Supporting, without a revision date, revealed, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently. Review of Resident 2's clinical record revealed diagnoses that included muscle weakness (weakness in the muscles causing decreasing ability to contract muscles) and malignant neoplasm of the frontal lobe (a cancerous brain tumor in the front of the brain in a portion that performs higher functions like reasoning and coordinated muscle movements). Review of Resident 2's current care plan dated May 28, 2024, revealed a focus area of, Resident at risk for functional decline in ADL's (activities of daily living), initiated of March 13, 2024. Review of Resident 2's clinical record failed to reveal any showers from April 13, 2024,…

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

Based on observation, completion of a test tray, and resident and staff interviews, it was determined that the facility failed to provide beverages that were palatable temperatures for one of one meals tested. Findings include: An interview with Resident 1 on April 1, 2024, at 10:54 AM, revealed the meals could be better and items are often served cold. Review of facility grievance logs from January 2024 to present, revealed a grievance filed on March 26, 2024, related to a prison style food system and that his meals are typically 45 minutes late. Observation of second floor meal service on April 1, 2024, at 12:44 PM, revealed all residents had been served on the unit. A test tray was completed on April 1, 2024, at 12:44 PM, utilizing a lunch tray served from the tray line steam table on the unit. The test tray included: meatloaf, mashed potatoes, peas and carrots, ice cream, milk, and coffee. Temperatures taken by Employee 1 (Dietary Manager) revealed the milk was 55.2 degrees and coffee was 116.2 degrees. Consequently, items were not palatable. During an interview with Employee 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.

Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for two of 24 residents reviewed (Residents 8 and 59). Findings include: Review of Resident 8's clinical record contained diagnoses included adult failure to thrive, dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), and muscle weakness. Observation on September 25, 2023, at 9:53 AM, in the hallway near the second floor nursing desk, revealed Resident 8 was in her tilt/recline wheelchair, and both blue plastic arm covers contained a light brown film. Observation with the Director Of Nursing (DON) on September 28, 2023, at 12:05 PM, in the dining room, revealed Resident 8 was in her tilt/recline wheelchair, and both blue plastic arm covers contained a light brown film. During an interview on September 28, 2023, at 12:05 PM with the DON, it was revealed that Resident 8's tilt/recline wheelchair arm covers should be cleaned. Review of Resident 59's clinical record…

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

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for two of 24 residents reviewed (Residents 52 and 62). Findings include: Review of Resident 52's clinical record on September 25, 2023, at approximately 11:00 AM, revealed diagnoses that included type II diabetes mellitus (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 52's Quarterly Minimum Data Set (MDS - assessment tool utilized to identify a resident's physical, mental, and psychosocial needs), with an assessment reference date of July 27, 2023, revealed that section N.; 0410 was coded to reflect that Resident 52 had received an antibiotic medication for the prior seven days. Review of Resident 52's clinical record revealed that Resident 52 did not receive an antibiotic medication during the July 27, 2023, MDS assessment look back period. During an electronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident comprehensive plan of care was reviewed and revised for three of 24 residents reviewed (Residents 45, 62, and 292). Findings include: Review of Resident 45's clinical record revealed diagnoses that included history of stroke (damage to the brain from interruption of its blood supply), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), and dysphagia (difficulty swallowing). Observation in Resident 45's room on September 25, 2023, at 11:20 AM, revealed a bottle of Glucerna (diabetic meal replacement formula) was being administered via a feeding pump. Review of Resident 45's September 2023 physician orders included Glucerna 1.5 at 65 milliliters per hour (ml/hr - 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 documentation, observation, and resident and staff interviews, it was determined that the facility failed to provide an ongoing program of activities designed to meet the needs, interests, and functional abilities of residents for two of two nursing floors (First and Second floor nursing units). Findings include: During resident interviews on September 25, 2023, at approximately 10:30 AM, Resident 17 reported that the facility cancels activities frequently. Further, during the resident interviews, Resident 52 also stated that the facility has canceled multiple activities. An interview with the residents who participated in the Resident Council group meeting on September 26, 2023, at 1:15 PM, revealed that 14 out of 14 residents in group revealed activities do not occur daily or as scheduled by the facility. Review of the facility's September 2023 Activity Calendar revealed that trivia is scheduled on the first floor on September 27, 2023, at 2:00 PM. Observation on the first floor on September 27, 2023, at 2:17 PM, revealed no activities occurring on 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 clinical record review and staff interview, it was determined the facility failed to complete a comprehensive assessment after a significant change in condition for one of 24 residents reviewed (Resident 81). Findings include: Review of resident 81's clinical record revealed diagnoses that included dysphasia (swallowing difficulties) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 81's current physician orders revealed an order for Homeland Hospice, due to unspecified protein calorie malnutrition, with an order date of August 23, 2023. Review of Resident 81's comprehensive care plan revealed, under the focus area, that Resident was admitted to Hospice services on August 16, 2023, due to unspecified severe protein-calorie malnutrition, with an initiation date of August 16, 2023. Review of Resident 81's MDS assessments (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs), revealed that a significant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility policy review, and staff interview, it was determined the facility failed to ensure a medication reconciliation of medications, record of disposition of medications, and documentation of medications dispensed was conducted upon discharge for one of three discharged residents reviewed (Resident 88). Findings include: Review of facility policy, titled Discharge With Medication, effective date of July 1, 2023, revealed it stated it was the facility's policy that, Medications are sent with the resident upon discharge from the facility only under conditions that protect the resident and assure compliance with applicable state laws. Review of section, titled Procedures, revealed in subsections A, F, H, and I stated, Medications may be sent with the resident on discharge if ordered by the prescriber. The prescriber should list the medications to be released upon discharge .Discharge medication information is listed in the order summary report in [the electronic health record] .The resident or responsible party should sign the Medication Release…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, policy review, and resident and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for one of 24 residents reviewed (Resident 47). Findings include: Review of Facility provided policy, titled Activities of Daily Living (ADLs), Supporting, revised March 2018, revealed, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident 47's clinical record revealed diagnoses that included hypertension (high blood pressure) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of…

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

Based on observation, policy review, staff interview, and record review, it was determined that the facility failed to ensure that a resident with a pressure ulcer received care consistent with professional standards of practice for one of 24 Residents reviewed (Resident 50). Findings include: A review of the facility wound care policy, titled Dry/Clean Dressings, last reviewed August 2023, stated, after cleaning the wound and applying treatment, apply the ordered dressing and secure; label with date and initials on top of dressing. A review of the clinical record for Resident 50 on September 28, 2023, revealed clinical diagnoses that included quadriplegia (paralysis of all four extremities, including the trunk) and stage IV sacral pressure ulcer (ulcer involving loss of skin layers, exposing muscle and bone of the large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity). A review of Resident 50's physician orders dated September 2023, included an order for wound care to the sacrum every day and evening shift. Observation of wound care 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 clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure that the physician documented a rationale for declination of a pharmacy review recommendation for two of 24 residents reviewed (Resident 28 and Resident 81). Findings include: Review of the facility policy, titled Medication Regimen Review (MRR), last reviewed dated 2006, revealed, Recommendations are acted upon and documented by the facility staff and or the prescriber. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. Review of Resident 28's clinical record contained diagnoses that included dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking) with behavioral disturbance, psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), anxiety (a feeling of worry, nervousness, or unease), and depression (feelings of severe despondency and dejection). 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 observations, facility policy review, and staff interviews, it was determined that the facility failed to ensure controlled substances were contained in a permanently affixed compartment for one of one medication rooms reviewed (second floor medication room). Findings include: Review of facility policy, titled Controlled Medicine Storage, (no date) revealed it was the facility's policy for, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Review of the policy's Procedure section revealed subsections A and B stated, The director of nursing and the consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications .Scheduled controlled medications and other medications subject to abuse are stored in a locked permanently affixed compartment separate from all other medications . During…

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