Gardens At West Shore, The

Based on observations, record review, and staff interviews, it was determined that the facility failed to ensure the environment meets the individual needs of each resident by ensuring the call system is within reach of the resident for one of 35 residents reviewed (Resident 155).Findings include: Review of the facility policy, titled Answering the Call Light, last reviewed August 21, 2024, revealed to ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. Review of Resident 155's clinical record revealed diagnoses that included type 2 diabetes mellitus (a chronic metabolic disorder characterized by the body's inability to properly use insulin, leading to high blood glucose levels) and hypertension (high blood pressure). Observation of Resident 155 on August 4, 2025, at 9:57 AM, revealed the Resident lying in bed, with their call bell on the floor on a fall mat to the left side of their bed, out of reach for the Resident. Observation conducted of Resident 155 on August 4, 2025, at 11:26 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 ensure that a resident's medication regimen was free from unnecessary psychotropic medications for one of seven residents reviewed for unnecessary medications (Resident 8).Findings include: Review of facility policy, titled Psychotropic Medication Use, with a last revised date of February 2025, revealed in section titled PRN Medication that 3. PRN [as needed] orders for psychotropic medications are limited to 14 days. a. For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, they will document the rationale for extending the use and include the duration for the PRN order. Review of Resident 8's clinical record revealed diagnoses that included post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event with triggers that can bring back memories of the trauma accompanied…

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 resident and staff interviews, it was determined that the facility failed to ensure a resident with limited range of motion and mobility received appropriate services, equipment, and assistance to maintain or improve range of motion or mobility for one of one residents reviewed (Resident 17).Findings include: Review of Resident 17's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting left dominant side and hypertension (high blood pressure). During an interview with Resident 17 on August 4, 2025, at 10:38 AM, Resident 17 indicated she was supposed to be getting a brace for my left leg and it is taking forever. Review of Resident 17's clinical record revealed a CRNP (Certified Registered Nurse Practitioner) visit note dated July 10, 2025, that indicated PT [Physical Therapy] Consult Request: Please evaluate the patient for lower left extremity…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, 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 11 of 38 residents reviewed (Residents 6, 7, 17, 43, 67, 74, 80, 83, 85, 109, and 142). Findings include: Review of Resident 6's clinical record revealed diagnoses that included atherosclerotic heart disease of the native coronary artery (cardiovascular disease involving plaque buildup in artery walls) and urinary tract infection (UTI - infection of any part of the urinary system). Review of Resident 6's current physician orders revealed an order to admit her to hospice services (medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness), effective September 6, 2024. Review of Resident 6's September 9, 2024, significant change comprehensive MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's…

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

Based on policy review, resident observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for seven of 38 residents reviewed (Residents 7, 80, 85, 96, 124, 142, and 171), and failed to give the opportunity to participate in the development, review, and revision of his/her care plan for one of 38 residents reviewed (Resident 61). Findings include: Review of facility policy, titled Care Planning - Interdisciplinary Team , last reviewed August 2024, revealed that each resident has the right to participate in choosing treatment options and must be given the opportunity to participate in the development, review, and revision of his/her care plan. Review of Resident 7's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning),Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it…

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 residents who require dialysis receive such services consistent with professional standards and failed to maintain complete and accurate records related to dialysis communication for one of two residents reviewed for dialysis (Resident 158). Findings include: Review of facility policy, titled End stage renal disease, Care of a Resident with, last revised January 2019, read, in part, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Examples of education and training of staff may include: The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis as required; Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed and may include: How information will be exchanged between the facilities. The resident's comprehensive care plan will reflect the resident's 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.

Based on review of select facility personnel documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for four of five nurse aides reviewed (Employees 11, 12, 13, and 15). Findings Include: Review of personnel information revealed that Employee 11's hire date was August 20, 2001; Employee 12's hire date was November 28, 2005; Employee 13's hire date was April 7, 2010; and Employee 15's hire date was January 11, 2022. Further review of personnel information for Employees 11, 12, 13, and 15, failed to reveal that annual performance reviews were completed. During an interview with the Nursing Home Administrator on September 26, 2024, at 12:35 PM, he acknowledged that he had no additional documentation to provide for the selected employees. He confirmed that he would expect annual performance reviews to be completed annually around an employee's date of hire. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.19(2) Personnel policies…

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 and five of five pantries. Findings include: Review of facility policy, titled General Food Preparation and Handling, last revised July 2023, read, in part, Procedure: The kitchen is kept neat and orderly. The kitchen and equipment are clean. All food service equipment should be cleaned, sanitized, dried, and reassembled after each use. Observation in the main kitchen on September 23, 2024, at 9:31 AM, revealed Employee 2 (Food Service Director) tested the sanitizer concentration of the three-compartment sink with test strips that expired May 1, 2024. Observation of the floor in the main kitchen next to the three-compartment sink on September 23, 2024, at 9:32 AM, revealed the floor was heavily soiled with a black and grey sludge. Observation in the main kitchen on September 23, 2024, at 9:33 AM, revealed the sugar and rice bins were not labeled 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 observations, clinical record review, policy review, and staff interviews, it was determined that the facility failed to maintain a safe and sanitary environment that supports infection prevention and control for three of 38 residents reviewed (Residents 15, 32, and 171). Findings include: A review of the facility policy, titled Enhanced Barrier Precautions, last revised April 2024 states the following: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering 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 personnel training records and staff interview, 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 and included dementia management training and resident abuse prevention training for three of five nurse aide employee records reviewed (Employees 11, 12, and 13). Findings Include: Review of personnel information revealed that Employee 11's hire date was August 20, 2001; Employee 12's hire date was November 28, 2005; and Employee 13's hire date was April 7, 2010. Review of facility training records failed to reveal that the aforementioned Employees completed 12 hours of required annual training in the past 12 months, or that they had completed dementia management training and resident abuse prevention training in the past 12 months. During an interview with the Nursing Home Administrator on September 26, 2024, at 12:35 PM, he confirmed that he had no additional information to provide that the selected staff had completed required annual education topics…

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 implement resident-directed care and treatment consistent with the resident's physician orders and plan of care for one of 35 residents reviewed (Resident 142). Findings include: Review of Resident 142's clinical record revealed diagnoses that included bipolar disorder (a mental health condition that causes extreme mood swings from depression to mania or hypomania) and diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident 142's physician orders revealed the following physician orders: Insulin Lispro Subcutaneous Solution Pen-injector 200 unit /ml (Insulin Lispro) Inject as per sliding scale: if 0 - 149 = 0 units or if not eating; 150 - 200 = 4 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 350 = 10 units; 351+ = 12 units, notify MD if BS (blood sugar) >400, subcutaneously three times a day, with a start date of September 1, 2024, and discontinued September 12, 2024. Insulin Lispro Subcutaneous Solution…

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, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for one of four residents reviewed for pressure ulcers (Resident 74). Findings include: Review of the facility policy, titled Skin and Wound Management System, last reviewed on August 2024, revealed that residents identified with skin impairments will have appropriate interventions, treatment, and services implemented to promote healing and impede infection. Review of Resident 74's clinical record revealed diagnoses that included hypertension (high blood pressure) and bradycardia (slow heart rate). Review of Resident 74's comprehensive care plan revealed a focus area for the Resident being at risk for skin integrity pressure, revised on July 16, 2024; and an intervention for heel list suspension boots when in bed, initiated on August 26, 2024. Observation of Resident 74 on September 23, 2024, at 9:42…

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, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one of 35 residents reviewed (Resident 63). Findings Include: Review of Resident 63's clinical record revealed diagnoses that included schizoaffective disorder, bipolar type (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, and mania), abnormal posture, and muscle weakness. Review of select facility report detailing the incident that occurred on June 27, 2024, read, in part: Incident Description: Nursing Description: I [Employee 4 (Registered Nurse)] was standing in the hallway down a little bit from [Resident 63's] room and [Employee 8 (Nurse Aide)] was standing there talking to me. She walked away and walked towards [Resident 63's] room, as she was walking…

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, interviews, and facility policy review, it was determined that the facility failed to ensure that one of 38 residents reviewed were monitored for acceptable parameters of weight (Resident 124). Findings Include: Review of facility policy, titled Weight Assessment and Intervention, last reviewed August 21, 2024, revealed: The nursing staff will measure resident weight on admission, and then weekly for four weeks. If no weight concerns are noted at this point, weights will be measured monthly thereafter or as per Dietician or MD. A review of the clinical record for Resident 124 revealed diagnoses that included psychosis (a mental disorder characterized by a disconnection from reality) and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). Further review of the clinical record for Resident 124 revealed a 34-pound weight loss (-15.32 % loss) between July 17, 2024, and August 17, 2024. A review of the recorded monthly weights indicated no weight was obtained…

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 ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one out of 35 residents reviewed (Resident 43). Findings include: Review of Facility Policy, titled Care Plans- Comprehensive Person-Centered, last revised September 2022, read, in part, Trauma-informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. Review of Resident 43's clinical record revealed she was admitted to the…

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

Based on facility documentation review, policy review, clinical record review, and staff interview, it was determined that the facility failed to provide pharmaceutical services to ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate accounting of controlled drugs when acquiring, receiving, dispensing, and or administering to identify possible diversion for one of three residents reviewed (Resident 177). Findings include: Review of facility policy, titled Disposal of Medications and Medication-Related Supplies, last reviewed August 2024, revealed the medication disposition form is kept with the medications for return until picked up by the pharmacy; the receiving pharmacy representative signs the form to indicate receipt and gives the yellow copy to a nurse representative. Review of Resident 177's clinical record revealed diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and hypertension (high 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.

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were free of unnecessary psychotropic medications for one of four residents reviewed (Resident 96). Findings include: Review of facility policy, titled Antipsychotic Medication Use, with a last revised date of December 2016 and a last review date of August 21, 2024, indicated, 17. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending Physician: a. General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation; b. Cardiovascular: orthostatic hypotension [form of low blood pressure that happens when standing after sitting or lying down]; arrhythmias [abnormal heart rhythm; c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; and d. Neurologic: Akathisia [a movement disorder causing a feeling of restlessness and an inability to stay still], dystonia…

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, as well as resident and staff interviews, it was determined that the facility failed to ensure a safe, comfortable, homelike interior on one of five nursing units observed (1300 unit). Findings include: Review of facility policy, titled Recommendations for Management of Patients/Residents During Hot Weather, dated June 2024, revealed, Monitor air temperatures in various parts of the building at regular intervals .Prior to predicted heatwaves, check air conditioning systems and supplies .Maintenance staff should make regular rounds and monitor building systems throughout the period of hot weather. During an interview with the Nursing Home Administrator (NHA) on July 8, 2024, at 9:15 AM, he confirmed that the facility was experiencing problems with the air conditioning on the 1300 unit. He revealed that supplemental, portable air conditioning units were brought in as needed to control the temperatures, the maintenance department was monitoring the temperatures, and that a quote was obtained to fix the air conditioning. During interviews with…

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

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 four residents reviewed (Resident 4). Findings include: Review of Resident 4's clinical record revealed diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and Nontraumatic Intracerebral hemorrhage (a type of stroke in which a ruptured blood vessel causes bleeding inside the brain). Further review of Resident 4's clinical record revealed that she had a fall on May 13, 2024, at 9:00 PM. Review of Resident 4's nursing progress note on May 14, 2024, at 11:00 AM revealed that Resident 4 was complaining of some tenderness to the right side of her forehead on palpation, with skin slightly raised in the area. Physician was notified with orders received for a head CT (computed tomography- a medical imaging technique used to obtain detailed internal…

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 that residents received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of four residents reviewed (Resident 1). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included unstageable pressure ulcer of the sacral region (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device; unstageable- full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured), hypertension (elevated blood pressure), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Further review of Resident 1's clinical record revealed that she went to an outpatient appointment with the wound clinic on April 30, 2024. Review of the wound…

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, review of facility documentation, policies and procedures, as well as resident and staff interviews, it was determined that the facility failed to ensure residents were free from neglect for one of four residents reviewed (Resident 4). Findings include: Review of facility policy, titled Abuse Policy last reviewed September 23, 2023, revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . as well as, The resident has a right to be treated with respect and dignity . Review of the clinical record for Resident 4 revealed diagnoses that included hypertension (high blood pressure) and anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) Review of Resident 4's clinical record revealed a progress note created on February 10, 2024, at 4:30 PM, by Employee 1 (Registered Nurse) that said the following: Resident was last changed 13:00 [1:00 PM]. While giving meds at 16:30 [4:30 PM] she asked 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, observations, and staff interview, it was determined that the facility failed ensure the resident received care, consistent with professional standards, to prevent pressure ulcers for one of six residents reviewed (Resident 1). Findings Include: Review of facility policy, titled Dressing, Dry/Clean, revised September 2013, revealed, Steps in the Procedure 1. Clean bedside stand. Establish a clean field. 2. Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached. 3. Tape a biohazard or plastic bag on the bedside stand or use a waste basket below clean field. 4. Position resident and adjust clothing to provide access to affected area. 5. Wash and dry your hands thoroughly. 6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly. 9. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. 10. Label tape or dressing with date, time 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 and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like environment in four resident rooms (Residents' 2, 3, 4, and 5 rooms). Findings include: Observation in Resident 2's room on January 11, 2024, at 1:00 PM, revealed the Resident was in bed and there were items on the floor to the right and left of the recliner, crumbs on the floor under and around the Resident's bed, and, in the bathroom, there was a broken dresser drawer on the floor with several items inside. Observation in Resident 2's room on January 11, 2024, at 1:04 PM, with Employee 1 (Licensed Practical Nurse), revealed the drawer to the nightstand was observed on the bathroom floor to the left of the sink in the corner. The front of the drawer was off and laying inside the rest of the drawer, as well as a compact disc, large greeting card, and bottom portion of a plastic bottle. The nightstand to the right of the bed (facing the bed) contained all three drawers; however, the top drawer had a different handle on it. To the right of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record reviews, resident rights, and staff interviews, it was determined that the facility failed to offer the option to formulate an advanced directive and provided no documentation pertaining to resident's choices for advanced directives, or documenting how the resident was informed of his/her right to develop a living will or advanced directive, for three of 38 records reviewed; and failed to document the correct code status on the care plan to match the POLST (Pennsylvania Orders for Life-Sustaining Treatment) for one of 38 residents reviewed (Residents 40, 54, 72, and 88). Findings include: A review of the clinical record for Resident 40 on November 14, 2023, revealed Resident with diagnoses that include Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Atrial Fibrillation (irregular and rapid heart-beat). A review of the POLST form dated May 20, 2022, revealed full code status…

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 six of 39 residents reviewed (Resident 4, 72, 77, 138, 143, and 151). Findings Include: Review of Resident 4's clinical record revealed diagnoses that included Multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves) and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Review of Resident 4's MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated August 21, 2023, revealed that section M0150. Risk of Pressure Ulcers/Injuries (Is this resident at risk of developing pressure ulcers/injuries?) was marked 0. No. Further review of Section M0300. C1. Number of Stage 3 pressure ulcers was marked 1, indicating Resident 4 has one…

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 review and revise the resident plan of care for four of 38 residents reviewed (Residents 22, 59, 69, and 72). Findings include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered, with a last revision date of September 2022, and a last review date of September 23, 2023, revealed: A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of Resident 22's clinical record revealed diagnoses that included hypertension (high blood pressure), personal history of COVID, chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure), and personal history 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 clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to provide assistance with activities of daily living for dependent residents for six of 33 residents reviewed (Resident 15, 17, 55, 69, 88, and 94). Findings include: Review of Resident 15's clinical record on November 15, 2023, at approximately 9:00 AM, reveled diagnoses that included diabetes mellitus type 2 (decreased ability of the body to utilize insulin for the transfer of glucose from the blood into the cells for nourishment) and congestive heart failure (CHF - decreased ability of the heart to pump blood through the body). Review of Resident 15's Nurse Aide Tasks documentation revealed Resident 15 was scheduled to have a shower or bed-bath every Monday and Thursday during the evening shift. Review of the documentation revealed that Resident 15 did not receive a shower or bed bath on Thursday, November 9, 2023, and Monday, November 13, 2023. Review of Resident 17's clinical record revealed diagnoses that included contracture of muscle (a permanent…

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 Medication Regimen Reviews were completed by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber for four of 39 residents reviewed (Residents 72, 77, 88, and 96). Findings include: Review of facility policy, titled Medication Regimen Review (Monthly Report), reviewed September 2023, revealed, The prescriber accepts and acts upon recommendations or rejects and provides and explanation for disagreeing. Review of Resident 72's clinical record revealed diagnoses that included depression, unspecified psychosis (a mental disorder characterized by a disconnection from reality), generalized anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), unspecified mood affective disorder (marked disruptions in mood), and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory…

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 residents were free from unnecessary antipsychotic medication for one of five residents reviewed for unnecessary medications (Resident 143). Findings include: Review of Resident 143's clinical record on November 14, 2023, at approximately 9:30 AM, revealed diagnoses that included hypertension (elevated/high blood pressure) and chronic kidney disease stage 3 (moderate decrease in the ability of the kidneys to filter toxins from the blood). Review of Resident 143's physician orders revealed that on June 22, 2023, Resident 143 was ordered Seroquel (an antipsychotic medication used to treat schizophrenia and other mental health disorders) 50 milligrams (mg - metric unit of measure) twice a day with the indication for use documented as unspecified encephalopathy (broad term used for a disease that alters functioning of the brain). Review of Resident 143's clinical record revealed a Consultant Pharmacist Communication to Physician (also referred to as a medication regimen review),…

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 and staff interviews, policy review, observations, and clinical record review, it was determined that the facility failed to implement infection control practices to prevent the transmission of infectious disease for one of one resident reviewed for transmission based precautions (Resident 105); failed to maintain a data collection system of surveillance for three of 12 months reviewed (December 2022, January 2023, and April 2023); and failed to maintain an effective infection control program related to the preparation and administration of medications to one of three Residents observed (Resident 7). Findings include: Review of the facility policy titled, Infection Control, last reviewed September 2023, revealed the facility will maintain a monthly line list of residents with infections for trending and outbreak potential, follow-up review of lab data is compared, and a monthly review is completed to identify trends to facilitate infection control surveillance. The purpose of the surveillance of infections is to identify both individual cases and trends 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 and staff interviews, it was determined that the facility failed to maintain a clean, comfortable, and homelike environment for five of 38 residents observed (Residents 14, 114, 137, 138, and 223). Findings include: Observation of Resident 14's Broda chair (a tilt-in-space positioning chair which prevents skin breakdown through reducing heat and moisture) on November 13, 2023, at 10:04 AM, revealed the presence of a dried white substance on the left arm rest and heavy hair build-up around all four wheels. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on November 15, 2023, at 1:28 PM, the aforementioned concerns were shared. During a follow-up interview with the NHA and DON on November 16, 2023, at 11:52 AM, the NHA indicated that Resident 14's Broda chair had been cleaned. She further indicated that she would expect homelike and cleanliness concerns be addressed when identified by staff. Observations of Resident 114's room on November 13, 2023, at 11:01 AM, and November 15, 2023, at 12:35 PM, revealed 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 review of facility policy, clinical record review, review of facility incident report, and staff interviews, it was determined that the facility failed to conduct a timely and thorough investigation to rule out abuse, neglect, or mistreatment following an unwitnessed fall for one of 12 residents reviewed for falls (Resident 138). Findings Include: Review of facility policy, titled Abuse Policy with last review date of September 23, 2023, revealed, The Facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse and neglect. The policy defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of Resident 138's clinical record revealed diagnoses that included unsteadiness on feet, repeated falls, mild cognitive impairment (a condition in which someone has minor problems with their…

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 a significant change assessment (change to hospice status) was completed for one of 38 residents reviewed (Resident 18). Findings include: A review of Resident 18's clinical record on November 14, 2023, revealed diagnoses that included Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Atrial Fibrillation (irregular and rapid heart-beat). Review of the clinical record for Resident 18 on November 14, 2023, revealed the Resident was ordered a consult with the hospice service (special kind of care that provide comfort, support, and dignity at the end of life) on July 21, 2023. On July 25, 2023, the facility completed a Significant Change Minimum Data Set (MDS - periodic assessment of resident's needs), but the significant change MDS was not coded for hospice under Section O. Special Treatments, Procedures, and Programs. On August 5, 2023, the physician wrote an order for an evaluation 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 clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 38 residents reviewed (Resident 88). Findings Include: Review of Resident 88's clinical record revealed diagnoses that included atherosclerotic heart disease (build-up of cholesterol plaques in the walls of the arteries causing obstruction of blood flow) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 88's physician orders revealed an order for Metoprolol Tartrate Tablet 50 MG, Give 1 tablet by mouth one time a day related to essential hypertension, Do not crush; Hold for Systolic Blood Presure <120 Give with food or immediately after meal, with a start date of July 21, 2023. Review of Resident 88's MAR (Medication Administration Record - documentation for medication/treatment administered or monitored), revealed that Resident 88's Metoprolol medication was administered when it should have been held…

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 interview, it was determined that the facility failed to provide care and services to promote healing and prevent worsening of pressure ulcers for one of four residents reviewed for pressure ulcers (Resident 143). Findings include: Review of Resident 143's clinical record on November 14, 2023, at approximately 9:30 AM, revealed diagnoses that included hypertension (elevated/high blood pressure) and chronic kidney disease stage 3 (moderate decrease in the ability of the kidneys to filter toxins from the blood). Review of consultative wound specialist documentation for Resident 143 revealed that, upon assessment on November 14, 2023, Resident 143 had a stage 4 pressure ulcer (wound of the skin produced by pressure over a bony prominence that extends to the bone and/or other connective tissue) to the left dorsal foot and a stage 3 pressure ulcer (wound of the skin produced by pressure over a bony prominence that extends through the skin to the deeper tissue but does not reach muscle or bone). Review of Resident 143's physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to answer a dietary consult in response to weight loss to maintain adequate nutritional status for one of 38 residents reviewed (Resident 88). Findings include: Review of facility policy, titled Weight Assessment and Intervention, last revised March 2019, revealed, Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Physician and Dietitian .The Dietitian and/or Certified Dietary Manager will review the individual weight records to follow individual weight trends over time, making recommendations as appropriate. Review of Resident 88's clinical record revealed diagnoses that included adult failure to thrive (Adult FTT - a decline seen in older adults, typically those with multiple chronic medical conditions), dementia (irreversible, progressive, degenerative disease of the…

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

Based on observations, clinical record review, policy review, and staff interview, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for one of 39 residents reviewed (Resident 8). Findings include: Review of the facility's Oral Inhalation Administration Policy, last reviewed September 2023, revealed under the Nebulizer section, W. When equipment is completely dry, store in a plastic bag with the resident's name and date on it, and X. Change equipment and tubing every seven days. Review of Resident 8's clinical record revealed diagnosis that included chronic kidney disease (CKD - a condition in which the kidneys are damaged and cannot filter blood as well as they should) and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Review of Resident 8's current physician orders reveal an order for Ipratropium-Albuterol Solution 0.5-2.5 milligrams / 3 milliliters two times a day one vial inhale orally for shortness of breath and wheezing, with a start…

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, staff interviews, and clinical record review, it was determined that the facility failed to ensure that it was free from a medication error rate of five percent or greater based on two medication errors out of 31 opportunities. Findings include: Observation of medication administration on November 15, 2023, at 8:42 AM, revealed Employee 1 (Licensed Practical Nurse) administering Symbicort Aerosol 80-4.5 MCG/ACT (Budesonide-Formoterol Fumarate) Inhaler and diclofenac sodium gel 1% to Resident 7. Review of Resident 7's physician orders revealed orders for Symbicort Aerosol 80-4.5 MCG/ACT (Budesonide-Formoterol Fumarate) two puffs (an inhaled medication) for acute respiratory failure with hypoxia (condition that occurs when the lungs cannot get enough oxygen into the blood) with specific directions to rinse mouth and spit after administration; and diclofenac sodium gel 1% apply to bilateral knees topically two times a day with specific directions to apply four grams for generalized osteoarthritis (degeneration of joint cartilage and the underlying bone, causing…

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 record review, staff interview, and policy review, it was determined that the facility failed to ensure documentation of controlled medication disposition and reason for one of three closed records reviewed (Resident 168). Findings include: Review of facility policy, titled Disposal of Medications and Medication-Related Supplies, last reviewed March 2023, confirms that disposition of the medication and reason for the disposition should be documented on the Resident's controlled substance record. A review of the clinical record for Resident 168 on November 15, 2023, revealed that the Resident was transferred to the hospital on October 7, 2023, and passed away at the hospital October 8, 2023. A review of the closed record controlled substance forms revealed the Resident was receiving Tramadol (controlled pain medication) 50 milligrams and had 17 tablets remaining at the time of transfer. The licensed staff failed to document the disposition (how the medication was disposed) or reason why the medication was disposed. A review of the closed record controlled substance forms…

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 and staff interviews, policy review, and record review, the facility failed to assist residents in obtaining routine and emergency dental services for one of 39 residents (Resident 4). Findings include: Review of the facility's Dental Examination/Assessment Policy, last reviewed September 2023, revealed that residents should be offered dental services as needed and, upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist. Review of Resident 4's clinical record revealed diagnoses that included Multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves) and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). During an interview with Resident 4 on November 13, 2023, at 10:13 AM, Resident 4 stated that he was not currently wearing his dentures because he only has them for his top teeth and is still waiting to get them for his bottom teeth. Resident 4 pointed to his TV stand and showed the surveyor…

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 provide care and services to heal and prevent infection of pressure ulcers for two of three residents reviewed for pressure ulcers (Residents 1 and 2). Findings include: Review of facility policy, titled Dressings, Dry/Clean, revision date September 2013, revealed, Steps in the Procedure, included, Put on clean gloves, Loosen tap and removed soiled dressing. Pull glove over dressing and discard into plastic or biohazard bag. Wash and dry your hands thoroughly .[open new dressing supplies] .Wash and dry your hands thoroughly. Put on clean gloves .Cleanse the wound with ordered cleanser .Apply the ordered dressing . Review of Resident 1's clinical record on October 24, 2023, at approximately 10:30 AM, revealed diagnoses that included stage IV pressure injury (wound of the skin that extends to the bone or other connective tissue) and major depressive disorder (mental health disorder characterized by low mood, decreased enjoyment in activities,…

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 reviews, and staff interviews, it was determined that the facility failed to ensure that residents were provided a written notice of his or her rights and services provided, as well as all rules and regulations governing resident conduct and responsibilities during their stay in the facility prior to or upon admission for three of six residents reviewed (Residents 1, 4, and 6). Findings include: Review of facility policy, titled admission Criteria with a last revision date of December 2016, revealed, 1. The objectives of our admission criteria policy are to: d) review with the resident, and/or his/her representative, the facility's policies and procedures relating to resident rights, resident care, financial obligations, visiting hours, etc. Review of Resident 1's clinical record revealed that they were admitted to the facility on [DATE]. Review of Resident 1's admission Agreement revealed that it was signed by their Resident Representative/Power of Attorney 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 observations and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for six of 100 resident rooms, one of five shower rooms, and two of five dining rooms reviewed (Resident's 1, 3, 5, 7, 8, and 9 rooms; the 100 unit shower room; and Dining Rooms on the 500 and 100 units). Findings include: Observation in Resident 7's room on August 8, 2023, at 6:20 AM, there was several areas of dried blood on the fitted sheet and draw sheet (small bed sheet placed crosswise over the middle of the bottom sheet of the mattress to cover the area between the person's upper back and thighs) on Resident 7's bed. The floor under the television contained black spots and crumbs and, in the bathroom, inside the door was a dried, light orange liquid on the floor. During an interview with Resident 7 on August 8, 2023, at 6:20 AM, it was revealed that his sheets were soiled with dried blood, and he asked staff to change his bed three days ago but it wasn't changed. Observation in Resident 7's room on August 9, 2023, at 11:46…

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 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 (ADL) for two of nine residents reviewed (Residents 3 and 5). Findings include: Review of Resident 3's clinical record revealed diagnoses that included neurocognitive disorder (major disorder characterized by a significant decline in at least one of the following: executive function, complex attention, language, learning, memory, perceptual-motor, or social cognition) and blindness. Further clinical record review revealed Resident 3 is dependent for bathing/showers, and that showers are scheduled for dayshift on Wednesday and Saturday. Review of Resident 3's bathing task documentation for a 30-day period revealed: bed baths were provided on July 26th, 2023, and August 5th and 9th, 2023; and showers were provided July 15th, 2023, and August 2nd, 2023. Further clinical record review revealed no documentation of a shower/bath or refusal to be…

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, record review, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice of two of nine residents reviewed (Residents 8 and 9). Findings include: Review of Resident 8's clinical record revealed diagnoses included respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) and receives oxygen therapy. Observations in Resident 8's room on August 8, 2023, at 2:00 PM and at 3:35 PM, with the Nursing Home Administrator (NHA), revealed Resident 8 was wearing her oxygen and the filter on the concentrator contained a grey, fuzz. During an interview with the NHA on August 8, 2023, at 3:35 PM, it was revealed that the oxygen concentrator filter needed to be cleaned. Review of Resident 9's clinical record revealed diagnoses that included heart failure (chronic condition in which the heart doesn't um blood as well as it should) and receives oxygen therapy. Observations in Resident 9's room on August 8, 2023, at 1:38 PM…

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

Based on observation and resident and staff interviews, it was determined that the facility failed to provide food at a safe temperature for one of one meal observed on the 500 hallway (Lunch Meal on August 8, 2023). Findings include: Interviews with multiple residents on August 8, 2023, revealed concerns with the quality and the temperature of food during mealtime. A test tray was completed during the lunch meal, on the 500 unit. Test tray temperatures were taken by Employee 1 (Food Service Director) in the 500 unit dining room, on August 8, 2023, at 12:22 PM, and revealed the following: Turkey 129 degrees Fahrenheit, not an adequate temperature Bread Dressing 163 degrees Fahrenheit, acceptable California Blend Vegetables 151 degrees Fahrenheit, acceptable Peach slices 40 degrees Fahrenheit, acceptable Coffee 129 degrees Fahrenheit, acceptable Fruit Punch 38 degrees Fahrenheit, acceptable Review of temperature monitoring form dated August 8, 2023, documented that the temperature of the turkey at the beginning of tray line was 178 degrees Fahrenheit. 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.

Based on observations, clinical record reviews, and staff interviews, it was determined that the facility failed to provide residents food that accommodates resident preferences for one of nine residents observed (Resident 3). Findings include: Review of Resident 3's clinical record revealed diagnoses that included neurocognitive disorder (major disorder characterized by a significant decline in at least one of the following: executive function, complex attention, language, learning, memory, perceptual-motor, or social cognition) and blindness. Review of Resident 3's meal ticket for August 8, 2023, revealed the lunch meal documented double portions. Observation made on August 8, 2023, at 12:32 PM, during the lunch meal, it was revealed that Resident 3 was served one slice of turkey. During an interview with Employee 1 on August 8, 2023, at 12:30 PM, it was revealed that, if a Resident requests additional food, it should be provided. During an interview with the Nursing Home Administrator on August 8, 2023, at 3:30 PM, it was revealed that double portions on a meal ticket 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.