Carlisle Skilled Nursing And Rehabilitation Center

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.

Based on review of employee files, facility policies and procedures review, and interviews with staff, it was determined that the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property by failing to attempt to obtain information from previous employers and/or current employers for new employees for five of five employees (Employees 1, 2, 3, 4, and 5) Findings include: Review of facility policy, titled Abuse Prohibition, revised October 24, 2022, revealed, The center will screen potential employees for a history of abuse, neglect, or mistreating patients including attempting to obtain information from previous employers and/or current employers for new employees, and checking with the appropriate licensing boards and registries. Review of Employee file for Employee 1 revealed a date of hire of July 18, 2023. Further review of the employee file failed to reveal attempt to obtain information from previous employers and/or current employers. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for five of 28 residents reviewed (Resident 8, 23, 76, 100, and 113). Findings Include: Review of Resident 8's clinical record revealed diagnoses that included depression (feelings of severe despondency and dejection), psychosis (a mental disorder characterized by a disconnection from reality), and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 8's physician's orders revealed orders for mirtazapine tablet 7.5 milligrams give 7.5 mg by mouth at bedtime for depression, dated January 19, 2022, and quetiapine (Seroquel) oral tablet 25 milligrams give 12.5 milligrams by mouth at bedtime for Psychosis, dated April 7, 2023. Review of Resident 8's psychiatry progress notes revealed a note dated May 3, 2023, which indicated…

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

Based on observation, clinical record review, facility policy review, and staff and resident interviews, it was determined that the facility failed to ensure that the resident care plan was reviewed and revised to reflect the resident's current care needs for four of 28 residents reviewed (Resident 1, 7, 38, and 80). Findings include: Review of the facility's Care Plan policy, with a revision date of September 24, 2022, under the section Updating and Revising the Care Plan: Including Resolving and Un-resolving the Focus, Goals, and Interventions, reveals that Care plans will be updated and revised as needed. Review of Resident 1's clinical record revealed diagnoses that included acute kidney failure (when your kidneys suddenly stop working) and hypertension (high blood pressure). Review of Resident 1's current physician orders revealed an order for the following: Apply [NAME] hose Q (every) AM and remove Q PM for increased edema, with an active date of July 30, 2023. Review of Resident 1's care plan (information pertaining to a resident's psychosocial, physical, and care 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 clinical record review and staff interviews, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders and care plan for three of 28 residents reviewed (Resident 1, 38, and 48). Findings include: Review of Resident 1's clinical record revealed diagnoses that included acute kidney failure (when your kidneys suddenly stop working) and hypertension (high blood pressure). Review of Resident 1's current physician orders revealed an order for the following: Apply [NAME] hose Q (every) AM and remove Q PM for increased edema, with an active date of July 30, 2023. Review of Resident 1's August TAR (treatment administration record) revealed 15 days in August 2023 that Resident 1 did not have a ted hose administered. The following dates were left blank: August 7, 19, 20, and 26, 2023. The following dates were marked '9', which means 'other/see nurses notes': August 6, 8, 9, 10, 11, 12, 21, 22, 23, and 25, 2023. Review of Resident 1's progress notes on August 5, 2023, revealed documentation that LPN…

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, facility documents review, and facility policy review, the facility failed to ensure the facility had sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services for three of 30 residents reviewed (Residents 22, 34, and 105). Findings Include: Review of facility policy, titled Activities of Daily Living (ADLs), Supporting, revised May 1, 2023, revealed, Documentation of ADL care is recorded in the medical record and is reflective of the care provided by nursing staff. Review of Resident 22's clinical record revealed diagnoses that included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) and Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). During an interview with Resident 22 on August 28, 2023, at 10:54 AM, Resident 22 stated that he is scheduled for showers twice a week, but that he doesn't always get them. He stated that he is told that there is not enough staff to assist him…

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 provide food at portion sizes to meet the nutritional needs of residents and ensure the menu was followed for one of one meal observed (lunch meal, August 30, 2023). Findings include: Review of the menu and diet extension sheet (menu items based on individual diets) for August 30, 2023, lunch meal, revealed the pureed diet texture should be served a 4 ounce (unit of measure) portion of mixed vegetables and sweet potatoes. Observation of tray line on August 30, 2023, at 12:47 PM, revealed Employee 12 used a red handled scoop to serve puree mixed vegetables and pureed sweet potatoes. Interview with Employee 6 (Dietary Manager) on August 30, 2023 at 12:55 PM, revealed the scoop used on tray line for pureed sweet potatoes and pureed mixed vegetables were 2 ounce scoops. Observation of tray line meal service on August 30, 2023 at 12:31 PM, revealed the dietary department ran out of sweet potatoes after five meals were served for the Arcadia unit, the remaining resident's that were allowed 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 policy review, clinical record review, and staff interviews, 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 five of five residents reviewed for immunizations (Residents 22, 23, 57, 95, and 105). Findings Include: Review of facility policy, titled IC 601 Pneumococcal Vaccination, revised November 15, 2022, revealed, Provide the patient/representative education (Vaccine Information Statement [VIS]) regarding the benefits and potential side effects of vaccination. Answer any questions. Document education, including VIS .If patient/resident representative refuses pneumococcal vaccination, provide information and counseling regarding the benefit of vaccination (VIS). Document education . Review of facility policy, titled IC600 Influenza Immunization Program, revised May 1, 2023, revealed, If patient/health care decision maker…

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

Based on observation, facility policy review, and staff and resident interviews, it was determined that the facility failed to provide residents access to grievance forms in a manner that honors the right to file grievances anonymously for three of eight residents present at the group interview (Resident 2, 34, and 89) Findings include: Observations on August 29, 2023, at 9:34 AM, and August 30, 2023, at 1:05 PM, on the [NAME] Wing nurses' station, revealed Ombudsman concern forms in a bin in between binders, that were not accessible for residents who ambulate in wheelchairs, and were not in a prominent location for residents to see. During an interview with Licensed Practical Nurse 1 on August 30, 2023, at 11:05 AM, he revealed that there were no grievance forms on the East Wing. During group interview with Resident Council on August 30, 2023, at 10:30 AM, Resident 34 revealed that they had to write a grievance down on a blank piece of paper due to staff not being able to find any grievance forms. Resident 2 and Resident 89 did not know where the grievance forms were located.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure 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 30 residents reviewed (Resident 29) Findings include: Review of Resident 29's clinical record revealed that Resident 29 was readmitted to the facility on [DATE]. Resident 29's clinical record revealed diagnoses that included depression (feelings of severe despondency and dejection), mood disorder (a disorder in which your general emotional state or mood is distorted or inconsistent with your circumstances and interferes with your body's ability to function), and anxiety (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Further review of Resident 29's clinical record revealed physician orders for: lorazepam oral tablet 0.5 milligrams…

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 resident and staff interviews, it was determined that the facility failed to provide care and services regarding showering for three of 30 residents reviewed (Residents 22, 34, and 105). Findings Include: Review of facility policy, titled Activities of Daily Living (ADLs), Supporting, revised May 1, 2023, revealed, Documentation of ADL care is recorded in the medical record and is reflective of the care provided by nursing staff. Review of Resident 22's clinical record revealed diagnoses that included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) and Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). During an interview with Resident 22 on August 28, 2023, at 10:54 AM, Resident 22 stated that he is scheduled for showers twice a week, but that he doesn't always get them. Review of Resident 22's curent care plan revealed a care plan dated January 11, 2023, for ADL self-care deficit related to physical limitations,…

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 evaluate for and implement interventions to prevent future accidents for two of four residents reviewed for falls (Residents 61 and 81). Findings include: Review of the clinical record for Resident 61 revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking and behavior) and abnormalities of gait and mobility. Review of nursing progress notes and incident report dated August 5, 2023, revealed that Resident 61 experienced an unwitnessed fall on that date that resulted in a nasal bone fracture and facial lacerations that required suturing. Review of Resident 61's care plan revealed a focus area: at risk for falls due to history of falls with a single intervention of therapy evaluation and treatment per orders. This care plan and intervention were effective August 1, 2023. Further review of Resident 61's clinical record failed to reveal evidence that the fall that occurred on August 5, 2023, was thoroughly…

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 precisely and effectively monitor nutritional status consistent with professional standards of practice for one of 28 residents reviewed (Resident 113). Findings include: Review of facility policy, titled Procedure: Weights and Heights last revised February 1, 2023, revealed admissions and re-admissions will be weighed within 24 hours of admission, and weights should be entered into the weights/vital signs module on the shift obtained. Review of Resident 113's clinical record on August 28, 2023, revealed diagnoses that included Unspecified protein calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets), pressure ulcer of sacral region (wound that occurs when the skin and tissue are damaged by prolonged pressure), and hypertension. Review of Resident 113's medical record revealed she was admitted to the facility on [DATE], 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 observation, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for three of six residents reviewed for oxygen (Residents 22, 29, and 30). Findings include: Review of facility policy, titled Procedure: Oxygen: Aerosol/Tracheostomy Mask/Collar, revised August 7, 2023, revealed, Provide oxygen source in room according to equipment specific procedure, if ordered .Replace entire set-up every seven days. Store in treatment bag when not in use. Review of Resident 22's clinical record revealed diagnoses that included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) and Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). Observation of Resident 22 on August 28, 2023, at 10:54 AM, and on August 29, 2023, at 12:12 PM, revealed Resident 22 wearing oxygen. Observations on those dates and times revealed that neither Resident 22's oxygen…

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 who require dialysis receive such services consistent with professional standards of practice and the comprehensive person-centered care plan for one of 28 residents reviewed (Resident 100). Findings include: Review of Resident 100's clinical record on August 28, 2023, revealed diagnoses that included end stage renal disease (ESRD- loss of kidney function), dependence on renal dialysis (a machine filters wastes, salts, and fluid from your blood when kidneys can no longer perform these functions naturally), and hypertension (high blood pressure). Review of Resident 100's physician orders revealed an order for: Dialysis site observation every shift and as needed every shift for monitoring, with a start date of April 30, 2023. Review of Resident 100's TAR (Treatment Administration Record- documentation for treatments/medication administered or monitored), revealed no documentation to indicate Resident 100's dialysis site was observed on June 21, 2023, July 14, 2023,…

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 documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually and that in-service education was provided based on the outcome of these reviews for two of five nurse aides reviewed (Employees 9 and 10). Findings Include: Review of select facility documentation revealed that Employee 9 was hired on June 13, 1995, and Employee 10 was hired on July 22, 1994. Review of employee performance evaluations for Employees 9 and 10 revealed that one was completed on June 15, 2022, for Employee 9, and one was completed on March 15, 2022, for Employee 10. During an interview with the Director of Nursing on August 31, 2023, at 1:27 PM, she confirmed that no additional performance evaluations were completed within the prior 12 months for either Employee 9 or 10. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

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 manage the final disposition of controlled substances for one of two closed records reviewed (Resident 122). Findings Include: Review of facility policy, titled Disposal/Destruction of Expired or Discontinued Medication, revised [DATE], revealed, Controlled substances may not be returned to the Pharmacy, unless refused at the time of the delivery Facility should destroy controlled substances in the presence of a registered nurse and a licensed professional or in accordance with Facility policy or Applicable Law. Destruction of controlled medications should be documented on the controlled medication count sheet and signed by the registered nurse and witnessing licensed professional who should record: Quantity destroyed; Date of destruction; and Signature of registered nurse and Licensed professional. Review of Resident 122's clinical record revealed Resident 122 passed away on [DATE]. 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 review of select facility forms and menus, observations, completion of a meal test tray, and resident and staff interviews, it was determined that the facility failed to provide food and beverages that were at an appetizing appearance, flavor, and temperature. Findings include: Review of facility document, titled Food and Nutrition Services Test Tray Evaluation, last revised May 1, 2023, revealed that hot food and beverages should be served above 140 degrees Fahrenheit (F - a unit of measure) and chilled food and beverages should be served at or below 55 degrees F. Multiple resident interviews on August 28, 2023, and August 30, 2023, revealed residents voiced concerns with the temperature, taste, and appearance of the food during meal service. During an interview with Resident 57 on August 28, 2023, at 10:12 AM, Resident 57 stated the food is not good and the temperature of the food is not hot enough for her. Interview with Resident 38 on August 28, 2023, at 10:19 AM, revealed the food is horrible and cold. Interview with Resident 423 on August 28, 2023, at 10:57 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 review of facility documentation and staff interview, it was determined that the facility failed to ensure that the Quality Assurance Committee met quarterly for one of four quarters reviewed (fourth quarter 2022). Findings include: Review of Quality Assurance Committee sign-in sheets revealed no evidence that the facility held a meeting during the fourth quarter of 2022 (October through December). During an interview with the Director of Nursing on August 31, 2023, at 11:40 AM, she confirmed that they were unable to locate information to verify a meeting was held during the aforementioned timeframe. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on facility policy review, clinical record review, and staff interviews, 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 two of five residents reviewed for immunizations (Residents 22 and 23). Findings Include: Review of facility policy, titled IC604 COVID-19 Vaccination, revised June 30, 2023, revealed, 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. Review of Resident 22's clinical record revealed that Resident 22 received doses one and two of the COVID-19 vaccination, and also received one booster dose. Further review revealed that Resident 22 refused additional COVID-19 boosters. Review of Resident 22'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.