Carlisle Skilled Nursing And Rehabilitation Center

Based on facility policy reviews, clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure staff implemented appropriate infection control guidelines during medication administration for two of six residents observed (Residents 1 and 79), during wound care for one of one resident observed (Resident 1), and failed to implement appropriate infection control precautions per facility policy and physician orders for one of 29 residents reviewed (Resident 65).Findings include: Review of the facility policy, titled Medication Administration General Guidelines, dated January 2025, revealed, in part, Hands are washed with soap and water and gloves applied before administration of .ophthalmic [eye] .enteral [feeding tube] medications. Hands are washed with soap and water again after administration and with any resident contact. Antimicrobial hand sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy. Review of facility policy, titled Medication Administration Enteral Tubes, dated…

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

Based on facility policy review, review of personnel files, and staff interviews, it was determined the facility failed to ensure abuse training upon hire was completed for two of five employees reviewed (Employees 7 and 13).Findings include: Review of facility policy, titled OPS300 Abuse Prohibition, with a last review date of November 14, 2025, revealed, in part, The Center will implement an abuse prohibition program through the following: Training of employees (both new employees and ongoing training for all employees); Training and reporting obligations will be provided to all employees - through orientation, Code of Conduct training, and a minimum of annually - and will include: 4.1 the Abuse Prohibition policy and 4.8 dementia management and patient abuse prevention. Review of personnel file for Employee 7 (Licensed Practical Nurse) revealed that her date of hire was April 28, 2026. Further review of the personnel file failed to reveal any documentation Employee 7 had completed any new employee orientation to include training on the facility abuse prohibition policy. 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 facility policy review, clinical record reviews, observations, and staff interview, it was determined that the facility failed to promote an environment that enhances each resident's dignity by storing incontinent briefs in open view for two of 29 residents reviewed (Residents 30 and 34).Findings include: Review of facility policy, titled OPS206 Resident Rights Under Federal Law with a last revised date of February 1, 2023, and a last review date of June 12, 2025, indicated under the section titled Purpose that the facility was to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her self-esteem and self-worth. Also, in Section 1 Resident Rights revealed 1.1 The facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. Review of Resident 30's clinical record revealed diagnoses that included anxiety (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 facility policy review, clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to determine a resident's right to self-administer medications was clinically appropriate for one of one resident reviewed (Resident 1).Findings include: Facility policy, titled Medication Administration General Guideline, dated January 2025, read, in part, 15. Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications and state regulations. Facility policy, titled Medications: Self-administration, last revised October 15, 2024, read, in part, Patients who request to self-administer medications will be evaluated for safe and clinically appropriate capability based on the patient's functionality and health condition. If it is determined that the patient is able to self-administer: A physician/advanced practice provider (APP) order is required. Self-administration 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 policy review and resident and staff interviews, it was determined that the facility failed to ensure the resident has the right to privacy when receiving mail and packages for two of 29 residents reviewed (Residents 4 and 110).Findings include: Review of the facility policy, titled REC214 Patient/Resident Mail Delivery with a last revised and reviewed date of July 17, 2026, revealed Patients/Residents have the right to privacy in written communications, to send and promptly receive unopened mail and other letters, packages, and other materials delivered to the Center/Community, including those delivered through a means other than a postal service, and to have access to stationery, postage, and writing implements at their own expense. Procedure: 1. The Recreation Director or designee will: 1.2 Ensure that mail is delivered to the person unopened or postmarked within 24 hours, including Saturday. During an interview with Resident 4 at the resident council meeting on July 21, 2026, at 1:30 PM, she revealed that staff at the facility have opened her mail thinking it was…

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

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to ensure the residents' right to a clean, comfortable, and homelike environment, including housekeeping and maintenance services, to maintain a sanitary, orderly and comfortable interior for three of 29 residents reviewed (Residents 6, 34, and 67).Findings include: Review of facility policy, titled OPS200 Safe and Homelike Environment, with a last revised date of November 14, 2025, revealed, in part, The resident/patient has the right to a safe, clean, comfortable, and homelike environment that de-emphasizes the institutional character of the setting. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation in Resident 6's room on July 20, 2026, at 10:40 AM; July 21, 2026, at 2:01 PM; and July 22, 2026, at 9:52 AM, revealed her wallpaper was torn and there were two large black scratch marks along the wall. During a staff interview with the Nursing Home Administrator (NHA), the Director of Nursing (DON), and 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 interviews, it was determined the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for one of 29 residents reviewed (Resident 6). Findings include: Review of Resident 6's clinical record revealed diagnoses that included displaced intertrochanteric fracture of the right femur, initial encounter for a closed fracture, muscle weakness, and low back pain. Review of Resident 6's clinical record revealed she had a Quarterly MDS (Minimum Data Set- assessment tool utilized to identify residents' physical, mental and psychosocial needs) Assessment on March 10, 2026, and her next assessment was an Annual MDS Assessment completed on July 16, 2026. During an interview with Employee 12 (MDS Coordinator) on July 22, 2026, at 2:41 PM, she revealed Resident 6 should have had an assessment completed every 3 months. During an interview with the Director of Nursing on July 23, 2026, at 1:03 PM, she revealed she would expect MDS assessments 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.

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 a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for one of 29 residents reviewed (Resident 1).Findings Include: Facility policy, titled OPS416 Person-Centered Care Plan, revision date September 15, 2025, read, in part, 1. Baseline Care Plan . 1.1.7. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the patient and patient representative, if applicable.1.1. 7.2. Interventions shall be initiated that address the patient's current needs including: 1.1.7.2.1 Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. 1.1.7.2.3 Any special needs such as for IV therapy, dialysis,…

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, resident council interviews, and resident and staff interviews, it was determined that the facility failed to provide necessary services to a resident who is unable to carry out activities of daily living (ADLs) to maintain personal hygiene for three out of five residents reviewed for ADL care (Residents 2, 3, and 28).Findings include: Review of the facility policy, titled NSG200 Activities of Daily Living (ADLs) with a last revised date of May 1, 2023, and a last review date of March 20, 2026, revealed, in part, Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's activities of daily living (ADL) abilities are maintained or improved and do not diminish unless circumstances of the patient's clinical condition demonstrate that a change was unavoidable. ADLs include: Hygiene - bathing, dressing, grooming, and oral care. And 5. Documentation of ADL care is recorded in the medical record and is reflective of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure that treatments were provided as ordered for two of 29 residents reviewed (Residents 99 and 106); failed to ensure catheter orders were complete for one of two residents reviewed for catheters (Resident 1); and failed to ensure consultation appointments were scheduled in a timely manner to meet each resident's physical, mental, and psychosocial needs for one of 29 residents reviewed (Resident 99). Findings include: Review of Resident 1's clinical record revealed diagnoses that included obstructive and reflux uropathy (blockage urine flow making it difficult or impossible to urinate) and benign prostatic hyperplasia with lower urinary tract symptoms (non-cancerous enlargement of the prostate gland causing trouble with urination). Review of Resident 1's comprehensive plan of care revealed that Resident 1 required an indwelling foley catheter 16 FR/10ml balloon due to neurogenic bladder. 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 facility policy review, observations, resident and staff interviews, and clinical record reviews, it was determined that the facility failed to ensure that a resident receiving wound care was consistent with infection control standards of practice regarding aseptic field at the bedside and hand hygiene for one of four residents reviewed (Resident 1); and failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent of a pressure ulcers for one of four residents reviewed (Resident 122).Findings Include: Review of the facility policy, titled Procedure: Wound Dressings, Aseptic last reviewed February 24, 2025, revealed, in part, the following steps: 3. Prepare a clean, uncluttered, disinfected surface. 4. Create an aseptic field at bedside and place clean barrier on over-bed table. Place supplies on barrier. Review of the facility policy, titled IC203 Hand Hygiene last reviewed March 20, 2026, read, in part, If a task requires gloves, perform hand hygiene before donning gloves 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, observation, and staff interview, it was determined that the facility failed to ensure that a resident admitted with an indwelling foley catheter was accurately assessed for the removal of the catheter for one of one resident reviewed (Resident 1).Findings include: Review of Resident 1's clinical record revealed diagnoses that included severe protein-calorie malnutrition (a severe nutritional deficiency caused by inadequate or absorption of protein and energy-calories), cancer of the tongue, and obstructive (functional blockage of urine flow which causes damage to the kidneys) and reflux (urine flows backward into the kidneys) uropathy (any condition affecting that affects the urinary system). Observation of Resident 1 on July 21, 2026, at 9:00 AM, revealed the presence of an indwelling foley catheter (a flexible tube placed through the urethra to the bladder to drain urine). Review of Resident 1's physician orders revealed an order for a voiding trial to start June 30, 2026. Bladder scan every eight hours. May insert a straight catheter (a flexible…

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 and staff interviews, it was determined that the facility failed to ensure that pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of five residents reviewed for pain management (Residents 47 and 122).Findings include: Review of facility policy, titled Pain Management last revised March 24, 2025, read, in part, Staff will continually observe and monitor patients for comfort and presence of pain and will implement strategies in accordance with professional standards of practice, the patient-centered plan of care, and the patient's choices related to pain management. Purpose: To maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain. An individualized, interdisciplinary, person-centered care plan will be developed and include: Non-pharmacological and pharmacological approaches. PRN (as…

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 provide the licensed pharmacist's report of a medication irregularity for two of five residents reviewed (Residents 3 and 112).Findings include: Review of the facility policy, titled Medication Monitoring Medication Regimen Review and Reporting with a last policy review date of March 10, 2026, revealed, 6. Resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician. 7. A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable format to nurses, physicians and the care planning team within 48 hours of MRR completion. Review of Resident 3's clinical record revealed diagnoses that included hypertension (high blood pressure) and dementia (the loss of cognitive functioning that interferes with a person's daily life and activities). Review of Resident 3's clinical record revealed that on January 11, 2026, a Medication Regimen Review (MRR) was performed…

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 nurse aide job description review, employee file reviews, and staff interview, it was determined that the facility failed to ensure required in-service training for nurse aides sufficient to ensure the continuing competence of nurse aides no less than 12 hours per year and/or include resident abuse prevention training for two of five nurse aide files reviewed for annual education requirements (Employees 10 and 11).Findings include: Review of facility document, titled Job Description: Nursing Assistant last revised November 23, 2020, read, in part, Must attend a minimum of 12 hours continuing education programs provided by the center in order to maintain certification. Review of Employee 10's annual education hours revealed she had only completed 2.38 hours of annual education and had not completed any abuse prevention training. Review of Employee 11's annual education hours revealed she had not completed any abuse prevention training. During an interview with the Director of Nursing on July 22, 2026, at 2:09 PM, she revealed she would expect nurse aides to complete at least…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure dental services were provided to meet resident needs for three of three residents reviewed (Residents 1, 2, and 3).Findings include: Review of Resident 1'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) and progressive multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves, which disrupts communication between the brain and the body). Review of Resident 1's clinical record progress notes revealed a Care Plan Meeting note dated October 2, 2025, at 8:38 AM, which indicated that Resident 1 and her Representative were present for the meeting and that Resident 1 wished to be seen by the dentist for possible dentures. Review of Resident 1's dental consultation dated November 18, 2025, and electronically signed by the dentist on November 23, 2025, revealed recommendations 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 clinical record review and staff interviews, it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident for one of three residents reviewed (Resident 2).Findings include:Review of Resident 2's clinical record revealed diagnoses that included generalized anxiety disorder (excessive and ongoing worry that is difficult to control and interferes with day-to-day activities) and major depressive disorder (persistent low or depressed mood and a loss of interest in activities).Review of Resident 2's physician's orders revealed an order for Lorazepam three times a day for anxiety.Review of Resident 2's November 2025 medication administration record (MAR) revealed that on November 3, 2025, at 2:00 PM and 10:00 PM, Resident 2's Lorazepam was marked NN, indicating no/see nurse notes.Review of Resident 2's nursing progress notes for November 11, 2025, failed to reveal any notes relating to Resident 2's Lorazepam administration.During an interview with the Director of Nursing (DON) on December 15, 2025, at approximately 12:30 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility provided documentation, and staff interviews, it was determined that the facility failed to provide notice of a resident's transfer to the Office of the State Long-Term Care Ombudsman for five of 11 residents reviewed for hospital transfers (Residents 27, 48, 79, 81, and 86). Findings include: Review of Resident 27's clinical record revealed diagnoses that included need for assistance with personal care, muscle weakness, and unsteadiness on feet. Review of Resident 27's clinical record revealed he was transferred out of the facility and admitted to the hospital on [DATE] and 19, 2025. Review of select facility documentation provided failed to reveal the representative of the Office of the Long-Term Care Ombudsman was notified of Resident 27's aforementioned hospitalizations. Interview with the Nursing Home Administrator (NHA) on June 26, 2025, at 9:57 AM, revealed he would expect notification of hospitalizations to the representative of the Office 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 clinical record review and staff interviews, it was determined that the facility failed to ensure that resident assessments accurately reflected the resident's status for four of 33 residents reviewed (Residents 48, 79, 86 and 105). Findings include: Review of Resident 48's clinical record revealed diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and depression. Review of Resident 48's Medicare 5 Day MDS (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) with the assessment reference date (last day of the assessment period) of October 15, 2024, revealed in Section N. Medications that she was coded as receiving an antianxiety medication and was coded as not receiving anticonvulsant. Review of Resident 48's October 2024 Medication Administration 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 review of facility policy, clinical record reviews, as well as staff, resident representative, and resident interviews, it was determined that the facility failed to ensure that the care plan was reviewed and revised to reflect the resident's current status for four of 28 residents reviewed (Residents 48, 77, 94, and 102), and that residents were given the opportunity to participate in the care planning process and failed to ensure care plan meetings were being completed for five of 28 residents reviewed (Residents 25, 26, 47, 59, and 79). Findings Include: Facility policy, titled OPS416 Person-Centered Care Plan, last reviewed May 7, 2025, read in part, 7. Care plans will be: 7.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. 8. Care Plan Meetings: 9. The Center has the responsibility to assist patients to participate by: 9.1 Extending invitations to patient and HCDM sent in advance; 9.3 Facilitating 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 observations, review of the clinical record, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for five of 28 residents (Residents 13, 27, 38, 79, and 102). Findings include: Review of Resident 13's clinical record revealed diagnoses that included cerebrovascular disease (conditions that affect blood flow to your brain) and scoliosis (a condition where the spine curves sideways). Review of Resident 13's clinical record revealed the Resident had a fall on March 27, 2025, at 12:00 PM, where staff were alerted that Resident 13 was seen to be sitting on the floor and trashcan across from toilet. Description of immediate action taken revealed that the medical director provided a new order for urine analysis with culture and sensitivity (UA/C&S) to rule out urinary tract infection (UTI) due to Resident falling three times in 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, record review, observations, and resident and staff interviews, it was determined that the facility failed ensure the resident received care, consistent with professional standards, to treat and prevent pressure ulcers for two of three residents reviewed (Residents 77 and 106). Findings Include: Review of facility policy, titled NSG236, Revised October 15, 2024, revealed in 6.10. Determine the need for heel off-loading, 6.13 Implement special wound care treatments/techniques, as indicated and ordered, and step 11. Review care plan and revise as indicated. Review of Resident 77's clinical record revealed diagnoses that included osteomyelitis of left ankle and foot (infectious inflammation of bone marrow) and diabetes (a disease that effects how the body utilizes and regulates blood sugar). Observation of Resident 77 on June 23, 2025, at 1:25 PM, revealed him sitting in his wheelchair in his room and two pressure off-loading boots were sitting beside his bed. Interview with Resident 77 at that time revealed that staff occasionally put the pressure…

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 document review and staff interview, it was determined that the facility failed to ensure employee performance reviews were completed yearly (at least every 12 months) for five of five employees reviewed (Employees 9, 12, 13, 14, and 15). Findings include: On June 25, 2025, at approximately 9:45 AM, a request for the most recent employee performance reviews for Employees 9, 12, 13, 14, and 15 was made to the Nursing Home Administrator (NHA). During a staff interview on June 26, 2025, at approximately 12:20 PM, the NHA revealed the facility did not have any record that an employee review was conducted within the past year for Employees 9, 12, 13, 14 and 15. During the staff interview, the NHA revealed it was the facility's expectation that employee performance reviews are completed yearly. 28 Pa code 201.18(b)(3)Management 28 Pa code 201.19(2) Personnel policies and procedures

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to discard expired medications in one of three medication carts observed (B Hall) and in one of two medication rooms observed (West Wing). Findings include: Review of facility policy, titled Storage of Medication, with a last review date of May 7, 2025, revealed Medications and biologicals are stored properly, following manufacturer or provider pharmacy recommendations to keep their integrity and to support safe, effective drug administration. Review of facility policy, appendix Medications with Shortened Expiration Dates, dated 2007, revealed that Novolog insulin should be discarded 28 days after opening and that the beyond use date after initially opening multi-dose injectable vials is 28 days unless otherwise specified by the manufacturer. Observation of the B Hall medication cart on June 24, 2025, at 9:16 AM, revealed a Novolog insulin vial with an open date of May 24, 2025. Observation of the [NAME] Wing medication room on June 24, 2025, at 9:27 AM, revealed two open…

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 manufacturer guidelines, observation, review of select facility temperature logs, and staff interviews, it was determined that the facility failed to utilize equipment in accordance with professional standards for food service safety in the main kitchen. Findings include: Review of manufacturer guidelines for Cle-Series Dishwashers, dated November 2012, revealed that the minimum temperatures using high-temperature sanitizing for single-tank models, such as CL44e, require a minimum wash temperature of 160 degrees F (Fahrenheit- unit of measure). Observation of the dish machine in the main kitchen on June 23, 2025, at 9:41 AM, revealed the temperature gauge on the machine read 152 degrees F for the wash temperature while in use. During an interview with Employee 1 (Certified Dietary Manager) on June 24, 2025, at 12:37 PM, he revealed the model of the dish machine was CL44e and provided the manufacturer guidelines for review. He further revealed he and the staff were under the impression that the dish machine required a minimum wash temperature of 150 degrees F.…

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 a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for one of one residents reviewed (Resident 287); and failed to provide the resident and their representative with a summary of the baseline care plan that includes, but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary for one of one resident's reviewed (Resident 287). Findings include: Review of facility policy, titled OPS416 Person-Centered Care Plan, with a last review date pf May 7, 2025, revealed, in part, 1. 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 facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to provide care and services regarding hygiene and bathing for one of 28 residents reviewed (Resident 48). Findings include: Review of facility policy, titled NSG200 Activities of Daily Living (ADLs), with a last review date of May 7, 2025, revealed, in part, Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's activities of daily living (ADL) abilities are maintained . 4.2 A patient who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene. 5. Documentation of ADL care is recorded in the medical record and is reflective of the care provided by nursing staff. ADL care will be documented in real time, as close to the time that care was provided and information obtained as possible. ADL care is documented every…

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 the facility failed to ensure each resident receives proper treatment and services to maintain hearing abilities for one of three residents reviewed for vision and hearing (Resident 42). Findings include: Review of Resident 42's clinical record revealed diagnoses that included stage 3 chronic kidney disease (when your kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood) and hypothyroidism (when your thyroid gland doesn't make and release enough hormone into your bloodstream). During an interview conducted with Resident 42 on June 23, 2025, at 9:52 AM, revealed that she was having difficulty hearing, and has requested to see a doctor as she has hearing aids but has lost her ability to hear adequately. Review of Resident 42's clinical record revealed a medical practitioner note written on April 11, 2025, at 1:45 PM, that read, in part, Resident 42 was seen for an acute visit for hearing loss, and that they will consult audiology for evaluation. Review of…

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

Based on review of clinical records, policy review, observation, and staff interviews, it was determined that the facility failed to provide restorative nursing care for range of motion exercises for two of four residents reviewed for limited range of motion (Residents 5 and 88). Findings include: Review of facility policy, titled Restorative Nursing last revised August 7, 2023, read, in part, Centers may provide restorative nursing programs for patients who: Will benefit from restorative programs in conjunction with formalized rehabilitation therapy. Restorative programs are coordinated by nursing or in collaboration with rehabilitation and are patient specific based on individual patient needs. A licensed nurse must supervise the activities in a restorative nursing program. Document: Daily on Restorative Nursing Record in ADL Point of Care. Review of Resident 5's clinical record revealed diagnoses that included dysphagia (swallowing difficulties) and vascular dementia (a decline in thinking skills caused by conditions that damage blood vessels in the brain, leading to reduced…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to manage or prevent pain consistent with professional standards of practice and the residents' goals and preferences for three of 28 residents reviewed (Residents 13, 27, and 287). Findings include: Review of facility policy, titled NSG 227 Pain Management, with a last review date of May 7, 2025, read, in part, Staff will continually observe and monitor patients for comfort and presence of pain and will implement strategies in accordance with professional standards of practice, the patient-centered plan of care, and the patient's choices related to pain management. Purpose is to design a plan of care to achieve an optimal balance between pain relief and preservation of function, in accordance with patient directed goals and preferences. 7. Center staff will report any observation or communication of pain to the nurse responsible for that patient. 9. Patients receiving…

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, review of grievances, and resident and staff interviews it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one out of three nursing units (West wing). Findings Include: During the initial pool process on June 23, 2025, and June 24, 2025, there were 10 residents who expressed concern to the survey team about call bell response time and/or staffing. Review of facility grievances from April, May, and June of 2025 revealed three grievances related to extended wait time for call bells to be answered. Review of Resident Council Meeting minutes for April, May, and June of 2025 revealed that residents present at the meetings complained about extended call bell wait times in April and May of 2025. During an observation on June 23, 2025, at 11:00 AM, in [NAME] wing, B-hall, there were call lights activated for rooms [ROOM…

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 dental services were provided to meet resident need for one of one resident reviewed for dental (Resident 14). Findings include: Review of Resident 14's clinical record revealed diagnoses that included anxiety disorder (a group of mental health conditions characterized by excessive, persistent, and disproportionate fear or worry) and dysphagia (swallowing difficulties). During an interview with Resident 14 on June 25, 2025, on 12:18 PM, revealed she had new dentures that do not fit her mouth, which results in her not being able to eat properly. Review of Resident 14's clinical record revealed she was last seen by the facility's dentist on August 16, 2024, with treatment notes that included the Resident is interested in having new dentures fabricated, and that a preauthorization was submitted and will follow up with the Resident following denture approval. Review of Resident 14's clinical record revealed a preauthorization for the Resident's dental claim was…

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

Based on review of facility policy, review of medication package insert, observations, and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to the preparation and administration of medications to four of four residents observed (Residents 19, 52, 87, and 109). Findings include: Review of facility policy, titled Medication Administration 7.5 Orals, with a last review date of May 7, 2025, revealed in part avoid touching any of the medication unless wearing gloves. Review of the instruction leaflet for Lantus-Solostar Insulin Pen, with a last revised date of February 23, 2016, revealed the following, in part, Always use a new sterile needle for each injection. A. Wipe the rubber seal with alcohol. B. Remove the protective seal from a new needle. C. Line up the needle with the pen and keep it straight as you attach it (screw or push on, depending on the needle type). Review of facility policy, titled Subcutaneous Insulin, with a last review date of May 7, 2025, failed to reveal any direction to cleanse the rubber…

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, observations, and staff interviews, it was determined that the facility failed to promote care for residents in a manner and environment that enhances each resident's dignity for four of four Residents reviewed (Residents 5, 25, 40, and 54). Findings include: Review of facility policy, titled OPS200 Accommodation of Needs, with a last review date of April 24, 2024, revealed, in part, that the Center's physical environment and staff behaviors should be directed toward assisting the patient in maintaining and/or achieving independent functioning, dignity, and wellbeing to the extent possible in accordance with the patient's own needs and preferences. Review of facility policy, titled OPS206 Resident Rights Under Federal Law, with a last review date of April 24, 2024, indicated under the section titled Purpose, that the facility was to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her self-esteem and self-worth. Also, in…

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 provide a notice of transfer to residents and/or resident representatives, or to the Office of the State Long-Term Care Ombudsman for eight of 11 residents reviewed for hospital transfers (Residents 5, 7, 22, 25, 27, 39, 54, and 103). Findings include: Review of Resident 5's clinical record revealed diagnoses that included vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults), cognitive communication deficit (difficulty in thinking and how someone uses language), and aphasia (loss of ability to understand or express speech). Review of Resident 5's clinical record revealed that the Resident was transferred to the hospital on April 19, 2024, and returned to the facility on April 24, 2024. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 18, 2024, at 10:40 AM, the NHA confirmed that the facility was unable to provide documentation that Resident 5's responsible party or the Pennsylvania State…

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 provide residents and/or resident representatives with the facility's bed hold policy upon transfer for seven of 11 residents reviewed for hospitalization (Residents 5, 7, 25, 27, 39, 54, and 103). Findings include: Review of facility policy, Bed Hold Notice - Deliver Upon Transfer, revised August 5, 2022, revealed that staff are to complete the Bed Hold Notice Form, deliver it to the resident or representative (if there is one), and note delivery of the notice in the electronic health record. Review of Resident 5's clinical record revealed diagnoses that included vascular dementia (brain damage caused by multiple strokes, which causes memory loss in older adults), cognitive communication deficit (difficulty in thinking and how someone uses language), and aphasia (loss of ability to understand or express speech). Review of Resident 5's clinical record revealed that the Resident was transferred to the hospital on April 19, 2024, and returned to the facility on April 24,…

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

Based on clinical record review and resident 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 30 residents reviewed (Residents 7, 25, 38, 39, 123, and 124). Findings include: Review of Resident 7's clinical record revealed diagnoses that included congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to meet your body's needs), chronic kidney disease (a condition characterized by a gradual loss of kidney function), and hypertension (high blood pressure). Interview with Resident 7 on July 15, 2024, at 12:30 PM, revealed he lost use of his leg when he was in the hospital, and he has been in therapy since he returned. Review of select documentation, titled Physical Therapy Evaluation, with a start of care date of May 21, 2024, revealed under section Range of Motion: does patient have limitation in lower extremity range of motion that interfered with daily function or placed resident at risk of injury in the last 7 days, it was…

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

Based on clinical record review, facility policy review, observation, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 27 residents reviewed (Resident's 5, 40, 41, and 113). Finding include: Review of facility policy, titled SNF Clinical System Process - Care Plan, last reviewed April 24, 2024, read, in part, Updating & Revising the Care Plan: Including Resolving and Un-resolving the Focus, Goals, and Interventions - Care Plans will be updated and revised as needed. When and How Often: Based on ongoing assessment and evaluation of Patients needs and according to OBRA Requirements, Within 7 days of admission, at MDS interval, Quarterly review, with change in condition as it occurs. Review of Resident 5's clinical record revealed diagnoses that included vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults) and the presence of a gastrostomy tube (a surgically placed device used to give direct access to one's stomach for supplemental feeding, hydration…

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 residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of four residents reviewed for limited range of motion (Resident 115). Findings include: Review of Resident 115's clinical record revealed diagnoses that included encounter for orthopedic aftercare (aftercare following joint replacement surgery), hereditary and idiopathic neuropathy (a group of inherited disorders that affect the peripheral nervous system), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Interview with Resident 115 on July 15, 2024, at 10:12 AM, revealed he had previously received therapy services, but he doesn't get out of bed much since then. Review of select documentation, titled Physical Therapy Discharge Summary, signed by Employee 5 (Physical Therapist) on March 22, 2024, revealed Discharge reason, maximum potential achieved, refer 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 observations, clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure respiratory care was provided in a manner consistent with professional standards of practice for three of five residents reviewed for respiratory care (Residents 41, 54, and 84). Findings include: Review of facility policy, Respiratory Equipment/Supply Cleaning/Disinfecting, revised July 15, 2021, revealed, Oxygen Concentrators: Rinse and dry the external filter weekly and PRN [as-needed] when visibly dusty and change oxygen delivery devices-every seven days and as needed for soiling. Review of Resident 41's clinical record revealed diagnoses that included respiratory failure with hypercapnia (when the lungs have difficulty removing carbon dioxide from the blood) and morbid (severe) obesity with alveolar hypoventilation (diminished respiratory drive related to obesity). Observations made on July 16, 2024, at 9:43 AM, and July 17, 2024, at 1:09 PM, revealed Resident 41 receiving supplemental oxygen via nasal canula. No date was noted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure pharmacy recommendations were appropriately acted upon for four of five residents reviewed for unnecessary medications (Resident 7, 25, 54, and 56), and one of one resident reviewed for insulin use (Resident 51). Findings include: Review of facility policy, titled Psychotropic Medication Use, Last revised October 24, 2022, revealed section two of Procedure, stated, Facility should comply with the Psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services ('CMS'), the State Operations Manual, and all other Applicable Law relating to the use of psychopharmacologic medications including gradual dose reductions. Review of facility policy, titled Medication Regimen Review (MRR), last revised June 1, 2024, read, in part, Facility should alert the medical director where MRRs are not addressed by the attending physician in a timely manner. The facility…

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 the resident medication regimen was free of unnecessary psychotropic medications for two of five residents reviewed for unnecessary medications (Residents 25 and 56). Findings include: Review of facility policy, titled Psychotropic Medication Use, last revised October 24, 2022, revealed section 10 of Procedure, stated, All medication used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for .efficacy . Review of Resident 25's clinical record revealed diagnoses that included dementia, anxiety, and depression. Review of Resident 25's current physician orders revealed that the Resident was receiving the following psychotropic medications: belsomra (medication used to treat difficulty falling and staying asleep) oral tablet 10 mg (milligrams) give one tablet by mouth at bedtime for insomnia, dated March 2, 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 observations, facility policy review, and staff interview, it was determined that the facility failed to place opened dates on medications in two of three medication carts observed (100 Hall and 200 Hall). Findings Include: Review of facility policy, titled 5.3 Storage and Expiration Dating of Medication, Biologicals, last reviewed April 24, 2024, read, in part, This Policy 5.3 sets forth the procedures relating to the storage and expiration dates of medication, biologicals, syringes, and needles. Procedure 5. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dated for opened medication. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. Observation of the 200 hall medication cart on July 17, 2024, at 9:01 AM, revealed open stock bottles of the following medications with no open date: stool softener 100 mg, chewable aspirin 81 mg, delayed release aspirin 81 mg, vitamin D3…

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

Based on facility policy reviews, observations, and staff interview, 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 three of three nourishment areas Findings include: Review of facility policy, titled Refrigerated/Frozen Storage, dated May 1, 2023, read, in part, Food stored under refrigeration/freezer storage is maintained in a safe and sanitary manner. Purpose: to prevent damage, spoilage, and contamination of products. All foods are labeled with the name of product and the date received and 'use by' date one opened. Manufacturer 'use by' dates are used until opened. Food and Nutrition Services employees observe and record equipment temperatures daily according to the Refrigerator/Freezer Temperature Standards. Review of facility policy, titled Food and Nutrition Services 'use by' dating guidelines, dated July 10, 2023, read, in part, Item: produce and thickened liquids, date with 'use by' date seven days after opening. Frozen food stored in the freezer, 'use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that each resident's medical record includes documentation that indicates the resident or resident's representative was provided education regarding the benefits and potential side effects of the pneumococcal and influenza immunizations for four of five residents reviewed for immunizations (Residents 17, 25, 47, and 107). Findings Include: Review of facility policy, titled IC600 Influenza Immunization Program, revised September 1, 2023, revealed, Obtain consent for influenza vaccination; patient immunization consent is documented in PointClickCare (PCC) [electronic health record] --Patient Informed Consent or Declination; document influenza vaccination refusals. If patient/representative or employee refuses influenza immunization, provide information and counseling regarding the benefit of immunization. If immunization refused, document patient's and/or representative's refusal of…

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

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide evidence that education was provided to Residents on the risks and benefits of the COVID-19 vaccine for three of five residents reviewed for immunizations (Residents 17, 25, and 107). Findings Include: Review of facility policy, titled IC604 COVID-19 Vaccination, revised February 7, 2024, revealed, Based on the patient's COVID-19 vaccination history, offer the vaccination following the manufacturer's recommended schedule. Obtain consent. In situations where COVID-19 vaccination requires multiple doses, the patient/patient representative/employee/visiting HCP [Healthcare Provider] is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects associated with the COVID-19 vaccine before requesting consent for administration of any additional doses. If a patient/patient representative refuses vaccination, document declination on the Immunization Record. 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 facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment on one of three units observed (East Lounge). Findings include: Review of facility policy, titled OPS200 Accommodation of Needs, with a review date of April 24, 2024, revealed, in part, that the Center's physical environment and staff behaviors should be directed toward assisting the patient in maintaining and/or achieving independent functioning, dignity, and wellbeing to the extent possible in accordance with the patient's own needs and preferences. Observation of East Lounge on July 15, 2024, at 10:52 AM, revealed that approximately 20 empty wheelchairs/specialty chairs used for resident mobility were stored. During this observation, Resident 26 was observed to ambulate into the lounge using their walker. Resident 26 stepped away from their walker to move an empty wheelchair that was pushed up against a table displaying a jigsaw puzzle. After moving the wheelchair, Resident 26 retrieved their walker and proceeded 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 clinical records, facility policy review, and staff interview, it was determined that the facility failed to ensure that all alleged violations involving abuse, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one of two residents reviewed (Resident 57). Findings include: Review of facility policy, titled OPS300 Abuse Prohibition, with a last revision date of October 24, 2022, and last review date of April 24, 2024, revealed, in part, under section titled External Abuse Reporting Requirements that reporting requirements as based on real (clock) time, not…

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 resident and staff interviews, it was determined that the facility failed to ensure that a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for one of 27 residents reviewed (Residents 378). Findings include: Review of Resident 378's clinical record revealed Resident 378 was admitted to the facility on [DATE], with diagnoses that included end stage renal disease (kidneys can no longer filter waste and excess fluids) and acute respiratory failure with hypoxia (not enough oxygen in the blood). During an interview on July 16, 2024 at 11:00 AM, with Resident 378, it was revealed that Resident 378 had a midline catheter and received dialysis treatment three times a week. Review of Resident 378's physician orders failed to document an order for hemodialysis or care needs surrounding hemodialysis. Review of Resident 378's baseline care plan failed to document…

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 comprehensive plan of care accurately reflected the status of two of 27 residents reviewed (Residents 56 and 83). Findings include: Review of Resident 56's clinical record revealed diagnoses that included Alzheimer's disease (progressive, irreversible degenerative brain disease that results in decreased contact with reality and decreased ability to perform activities of daily living) and type two diabetes mellitus (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment). Review of Resident 56's physician orders revealed that on January 26, 2024, revealed Resident 56 was started on Rexulti (an atypical antipsychotic medication used to treat mental health disorders) 0.5 milligrams (mg - metric unit of measurement). On February 8, 2024, Resident 56's order for Rexulti was discontinued and Resident 56 was started on risperidone (antipsychotic medication used to treat mental health disorders)…

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

Based on facility policy review, observations, clinical record review, and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 27 residents reviewed (Resident 5). Findings Include: Review of facility policy, titled 5.3 Storage and Expiration Dating of Medications, Biologicals, with a last revision date of August 7, 2023, and last review date of April 24, 2024, revealed 13. Bedside Medication Storage: 13.1 Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration; and 13.2 Facility should store bedside medications or biologicals in a locked compartment within the resident's room. Review of Resident 5's clinical record revealed diagnoses that included vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults), cognitive communication deficit (difficulty in thinking and how someone uses language), and muscle…

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 each resident received treatment in accordance with professional standards of practice for two of 27 residents reviewed (Residents 113 and 378). Findings Include: Review of Resident 113's clinical records revealed diagnoses that included acute renal failure (ARF - a sudden and often reversible decrease in kidney function), short bowel syndrome (condition that occurs when the small is damaged preventing absorption of nutrients from food), and protein-calorie malnutrition (nutritional state where the body doesn't get enough protein, calories, or other nutrients causing changes in body composition and function). Review of Resident 113's physician orders revealed an order for a left double lumen PICC (peripherally inserted central catheter): inserted June 21, 2024 at 2:58 PM. Further review of Resident 113's physician orders revealed no orders for monitoring Resident 113's PICC line site and PICC line site dressing changes. Review of Resident 113's physician progress…

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, policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections and complications related to the use of a foley catheter (small, flexible tube that can be inserted through the urethra and into the bladder, allowing urine to drain) for two of two residents reviewed for catheter use (Residents 12 and 40). Findings Include: Review of facility policy, titled Catheter: Indwelling Urinary - Care Of, revised February 1, 2023, revealed, Secure the catheter tubing to keep the drainage bag below the level of the resident's bladder and off the floor. Review of Resident 12's clinical record revealed diagnoses that included malignant neoplasm of bladder (bladder cancer) and retention of urine. Observations on July 15, 2024, at 10:14 AM and at 10:49 AM, revealed Resident 12 had a urinary catheter, and the catheter drainage bag was laying on the floor next to her bed, doubled over onto itself. When informed of the concern at 10:52 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, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to monitor hydration status precisely and effectively for one of 27 residents reviewed (Resident 7). Findings include: Review of facility policy, titled Nutrition/Hydration Care and Services, last revised February 1, 2023, read, in part, Practice Standards: Maintain fluid and hydration balance. When a physician orders a fluid restriction due to specific clinical condition, dietary will calculate the amount of fluids to be provided on the meal trays, nursing will calculate the remaining amounts of fluids allotted for each shift. Inform the patient and/or patient representative of fluid restriction. Review of Resident 7's clinical record revealed diagnoses that included congestive heart failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to meet your body's needs), chronic kidney disease (CKD - a condition characterized by a gradual loss of kidney function), 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 observation, review of facility policy and documents, and staff interviews, it was determined that the facility failed to provide foods and beverages that are palatable, and at a safe and appetizing temperature for one of one meal observed on the Arcadia unit. Findings include: Review of facility policy titled Food Handling dated May 1, 2023, indicated 24. During transportation of food from the kitchen to the dining rooms, resident rooms, or other dining locations, care is taken to keep hot food hot and cold food cold and protected from contamination. Review of HACCP (Hazard Analysis Critical Control Point) Food Flow Chart, undated, provided by the facility indicated that ground meats and portioned meats should be maintained at a temperature of 145 degrees Fahrenheit or above. Observation on May 6, 2024, at 12:47 PM, revealed that two food delivery carts arrived on the Arcadia unit. A test tray was completed on May 6, 2024, at 1:05 PM on the Arcadia Unit from cart 2. Test tray temperatures were taken by Employee 1 (Dietary Manager) on the tray. Findings were as follows:…

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.