Claremont Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility admission agreement, closed clinical records, resident account statements, and staff interview, it was determined that the facility failed to convey resident fund account balance and overpayment balance upon discharge in accordance with State law for three of three closed resident records reviewed (Residents 1, 2, and 3). Findings include: A review of the facility policy, titled Resident Personal Funds, last revised [DATE], stated, Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility will convey within 30 days the resident's funds and a final account of those funds to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law. A review of the facility admission agreement stated the following,10.2 Refunds of Personal Funds. Any personal funds or valuables of Resident held by the Facility will be refunded .within thirty (30)…

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 resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for three of 35 residents observed (Residents 156, 167, and 252); and failed to maintain a safe, clean, and home-like environment on one of six nursing units observed (Heritage Harbor). Findings include: Review of facility policy, titled Routine Cleaning and Disinfection, with a last review date of March 26, 2024, revealed, in part, It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment; Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge; Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to: f. toilet seats; h. Resident chairs; Cleaning of walls, blinds, window curtains will be conducted when visibly…

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, personnel file review, and staff interview, it was determined that the facility failed to ensure that residents were protected from potential for abuse by failing to perform criminal history background checks prior to hire for three of five personnel files reviewed (Employees 3, 4, and 5). Findings Include: Review of facility policy, titled Abuse, Neglect and Exploitation, dated 2022, revealed, Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Review of the personnel file for Employee 3 (Registered Nurse) revealed no evidence that a Pennsylvania State Police background check or an FBI background check (for new hires that have not resided in Pennsylvania for two years) was completed prior to her hire on September 4, 2024. Review of personnel file for Employee 4 (Nurse Aide) revealed no…

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 provide respiratory care consistent with professional standards of practice for one of four residents reviewed for respiratory care (Resident 369). Findings include: Review of facility policy, titled Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy), undated, revealed, The facility will obtain an order for the use of a CPAP, BiPAP, AVAPS or Trilogy device and settings from the practitioner. Review of Resident 369's clinical record revealed diagnoses that included congestive heart failure (CHF - weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues) and obstructive sleep apnea (sleep disorder that causes breathing pauses during sleep due to a blockage of the upper airway). Observation on October 28, 2024, at 1:53 PM, revealed a CPAP machine (delivers a continuous stream of air, preventing airway collapse from obstructive sleep apnea) present on Resident 369's bedside stand. During an…

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

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for two of 35 residents reviewed (Residents 25 and 136). Findings include: Review of facility policy, titled Skin Assessment, undated, with the last review date of March 26, 2024, revealed, in part, A full body, or head to toe, skin assessment should be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. Review of Resident 25's clinical record revealed diagnoses that included type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel resulting in too much sugar circulating in the bloodstream) and edema (swelling caused by excess fluid accumulation in the body tissues). Review of Resident 25's…

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

Based on observations, clinical record review, and resident and staff interviews, it was determined the facility failed to ensure each resident receives proper treatment and assistive devices to maintain vision abilities for one of one resident reviewed for vision (Resident 240). Findings include: Review of Resident 240's clinical record revealed diagnoses that included chronic kidney disease (CKD - a long-term condition that occurs when the kidneys are damaged and cannot filter blood properly) and hypertension (high blood pressure). During an interview with Resident 240 on October 28, 2024, at 10:53 AM, revealed he was on the list to get his eyes examined in the beginning of this month (October 2024) but that did not occur, and Resident 240 was never told why or if it was rescheduled. Review of Resident 240's clinical record revealed a nursing progress note dated October 4, 2024, at 1:41 PM, with the following text: Resident to see by the optometrist on October 1, 2024. Will be seen on next visit due to time constraint. Observation at the third-floor nurses' station on October 29,…

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 provide appropriate care and services to residents receiving tube feedings for one of five residents with tube feedings reviewed (Resident 2). Findings include: Review of facility policy, titled Appropriate Use of Feeding Tubes, revised 2023, revealed the interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the initiation, continuation, or discontinuation of a feeding tube. Review of Resident 2's clinical record revealed diagnoses that included aphagia (a severe condition characterized by the inability to swallow, leading to persistent drooling and the inability to eat or drink) and dysphagia (difficulties swallowing). Observation of Resident 2 on October 21, 2024, at 11:25 AM, revealed that the Resident was lying in bed. Beside the Resident's bed was a pole with tube feeding and water flush hanging. The tube feeding was infusing at 60 cc per hour and the water was infusing at…

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, observation, record review, and staff interview, the facility failed to complete a risk-benefit analysis and obtain consent for enabler bar use for one of six residents reviewed for enabler use (Resident 33). Findings include: Review of facility policy, titled Proper Use of Bed Rails, dated 2023, with a last review date of March 26, 2024, revealed, in part, It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails; 1. As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms; b. Size and weight; c. Sleep habits; d. Medication(s); e. Acute medical or surgical interventions; f. Underlying medical conditions; g. Existence of delirium; h. Ability to toilet self safely; i. Cognition; j. Communication; k. Mobility (in and out of bed); and l. Risk of falling; 2. The resident assessment must also assess 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, policy review, and staff interviews, it was determined that the facility failed to ensure that the drug regimen of each resident was reviewed at least monthly by a licensed pharmacist, that irregularities were reported to the appropriate parties, and that these reports were acted upon in a timely manner for two of five residents reviewed for unnecessary medications (Residents 100 and 147). Findings include: Review of facility policy, titled Medication Regimen Review, undated, revealed, The consultant pharmacist should schedule at least one monthly visit to the facility, and shall allow for sufficient time to complete all required activities .Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Review of Resident 100's clinical record revealed diagnoses that included dementia with behavioral disturbance (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and major depressive disorder (mental disorder…

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

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice related to wound assessments for one of six residents reviewed (Resident 5). Findings include: Review of Resident 5's clinical record revealed diagnoses that included atherosclerosis (buildup of plaque in the walls of arteries causing reduced blood flow) and type two diabetes mellitus (the body does not make enough insulin or cannot use it as well as it should). Review of Resident 5's nursing progress notes revealed a note dated June 2, 2024, at 10:44 PM, that stated, called Gentiva Hospice RN [Registered Nurse] about resident wound deterioration to LLE (left lower extremity) who stated to refer to wound team asap on Monday, covering dressing applied for now, area cleansed as ordered, MD notified, left message for Family member. Review of progress note dated June 3, 2024, at 10:35 PM, stated, Resident started on doxycycline 100 mg for left shin wound. No adverse effect noted, tolerated well.…

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

Based on record review and staff interviews, it was determined that the facility failed to maintain an effective pest control program for one of four months reviewed (May 2024). Findings Include: Review of Resident 5's clinical record revealed diagnoses that included atherosclerosis (buildup of plaque in the walls of arteries causing reduced blood flow) and type two diabetes mellitus (the body does not make enough insulin or cannot use it as well as it should). Further review of Resident 5's clinical records revealed a wound care note dated June 3, 2024, that stated maggots were present in Resident 5's left anterior shin wound. A staff interview on July 11, 2024, at 10:35 AM, with Employee 2 (Registered Nurse) revealed, Employee 2 was one of the registered nurse supervisors for the building the evening of June 2, 2024. Employee 2 stated that she and was notified around 9:30 PM - 10:00 PM by the licensed practical nurse on the floor that Resident 5's wound looked different than it had previously. Employee 2 stated she went and assessed it (she said she had never seen it prior).…

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, facility document review, clinical record review, and staff interviews, it was determined that the facility failed to report sexual abuse to the State Agency within the specified timeframes for two of two incident reports reviewed. Findings Include: Review of facility policy, titled Abuse, Neglect and Exploitation, dated 2022, revealed 'Sexual Abuse' is non-consensual sexual contact of any type with a resident. Further review of the policy revealed: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. 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 b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. B.…

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

Based on observations, facility policy review, and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of 35 residents reviewed (Residents 36) and in two of two dining rooms observed (Heritage Hall dining area and Second Floor dining area). Findings include: Review of facility policy, titled Homelike Environment, with a last review date of March 28, 2023, indicated, in part, 2.The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment. Observation of Resident 36's room on December 11, 2023, at 10:06 AM, revealed that their overbed table had missing laminate and the plywood surface was visible, there was a brown substance/stain on privacy curtain between their bed and their roommate's bed, and that there was a dark red stain on privacy curtain at door. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on…

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

Based on policy review, review of facility documentation, clinical record review, and staff and resident interviews, it was determined that the facility failed to ensure that prompt efforts were made to resolve grievances/concerns for one of 35 residents reviewed (Resident 199). Findings: Review of the facilities policy, titled Resident and Family Grievances, last reviewed and approved on March 28, 2023, revealed the facility will make prompt efforts to resolve grievances.' Review of the facilities policy, titled Resident Lost Items Policy, last reviewed and approved on March 28, 2023, revealed in the event of the loss of basic off-the-shelf clothing, the facility will replace the lost clothing with similar items. Review of Resident 199's clinical record revealed diagnoses that included essential hypertension (high blood pressure) and gastro-esophageal reflux disease (when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Review of the facility's Resident Council Meeting Minutes held on October 18, 2023, revealed under the Other questions/comments…

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

Based on review of the clinical record and resident and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 35 residents reviewed (Residents 86 and 129). Findings include: Review of Resident 86's clinical record revealed diagnoses that included history of pulmonary embolism (a sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs) and sequelae of cerebral infarction (neurologic deficits that persist after the initial episode of a stroke). Review of Resident 86's physician orders on December 11, 2023, at 12:30 PM, revealed an order for Pradaxa (anticoagulant) Oral Capsule 150 MG (Dabigatran Etexilate Mesylate) give one capsule by mouth two times a day related to cerebral infarction, unspecified, with an order date of November 8, 2023. Further review of Resident 86's physician orders failed to reveal any orders for monitoring for side effects of anticoagulant…

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, manufacturer product label review, and staff interviews, it was determined that the facility failed to discard expired medication in one of three medication rooms observed (second floor medication room); failed to properly store and label drugs in two of four medication carts observed (third floor, west hall medication cart and second floor, west hall medication cart); failed to properly store medications inside a locked medication cart for one of two medication carts observed during a medication pass observation (first floor); and failed to lock a mediation cart when not in direct sight of a staff member. Findings Include: Review of facility policy, titled Administering Medications, revised December 2021, revealed, The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. Review of facility policy, titled Administering Medications, with a last review date of March 28, 2023, revealed 16. During administration 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, observations, and staff interviews, it was determined that the facility failed to store food and equipment in accordance with professional standards for food service safety in the main kitchen and five of six nourishment areas. Findings include: Review of facility policy, titled Labeling and Dating Food Items, last revised December 2020, revealed, All food items opened or removed from their original packaging will have a 'use by' date. Review of facility policy, titled Use and Storage of Food Brought in by Family or Visitors, last reviewed March 28, 2023, revealed, All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. The prepared food must be consumed by the resident within 3 days. If not consumed within 3 days, food will be thrown away by the facility staff. Observation of the dry storage area on December 11, 2023, at 9:35 AM, revealed: one package of instant mushroom gravy not dated; one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, policy review, and resident and staff interviews, it was determined that the facility failed to ensure that the clinical record accurately reflected the resident preference for code status for one of 35 residents reviewed (Resident 81). Findings include: Review of facility policy, titled Advanced Directives, last revised [DATE], revealed, Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation, subsection six, the resident has the right to refuse treatment, whether or not he or she has an advance directive. A resident will not be treated against his or her own wishes. Residents who refuse treatment will not be transferred to another facility unless all other criteria for transfer are met. Review of Resident 81's clinical record revealed diagnoses that included essential primary hypertension (abnormally high blood pressure that is not the result of a medical condition) and unspecified atrial…

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

Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 35 residents reviewed (Resident 87). Findings include: Review of Resident 87's clinical record revealed diagnoses that included Pressure ulcer of left ankle, stage 4 (injury to skin and underlying tissue caused by prolonged pressure on the skin), and morbid obesity (a complex disease that involves having too much body fat and increases the risk of many other diseases and health problems). Review of Resident 87's physician orders revealed an order for, Air Mattress every shift for pressure injury Check function and setting, with a start date of December 1, 2023. Observation in Resident 87's room on December 11, 2023, at 1:26 PM, revealed he was not laying on an air mattress. Observation in Resident 87's room on December 12, 2023, at 10:19 AM, revealed he was not laying on an air mattress. Review of Resident 87's MAR (Medication Administration Record - documentation 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, observation, and resident and staff interviews, it was determined that the facility failed to provide assistance with activities of daily living for dependent residents for one of 35 residents reviewed (Resident 34). Findings include: Review of Resident 34's clinical record revealed diagnoses that included rheumatoid arthritis (when the body's immune system mistakenly attacks its own body's tissues, causing pain, swelling, and deformity) and osteoporosis (a condition when bone strength weakens and is susceptible to fracture). Observation of Resident 34 in her room on December 11, 2023, at 10:34 AM, revealed her hair looked greasy. Interview with Resident 34 on December 11, 2023, at 10:36 AM, revealed staff is not always giving showers on her preferred shower day. Review of Resident 34's Nurse Aide Tasks documentation revealed Resident 34 was scheduled to have a shower every Monday and Thursday during the evening shift. Review of the documentation revealed that Resident 34 received a bed bath instead of a shower on November 16, 23, 27, and 30, 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 record review and staff interviews, it was determined that the facility failed to prevent accident and hazards for one of 35 residents reviewed (Resident 139). Findings: Review of Resident 139's clinical record revealed diagnoses that included essential hypertension (high blood pressure) and stage 3 chronic kidney disease (when your kidneys do not work as well as they should to filter waste and extra fluid out of your blood). Review of Resident 139's current comprehensive-centered care plan revealed a focus area that the Resident is at risk for falls, with an initiation date of June 14, 2022, and a revision date of December 5, 2022. Intervention areas included bilateral fall mats, date initiated on June 30, 2022. Observation on December 11, 2023, at 10:56 AM, revealed Resident 139 laying in bed with no fall mats on the floor. Observation on December 13, 2023, at 12:11 PM, revealed Resident 139 laying in bed with no fall mats on the floor. Review of fall incident reports completed by the facility revealed that Resident 139 had falls on the following dates: September 17 and…

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

Based on observations, clinical record review, staff interview, and facility policy review, it was determined that the facility failed to provide the physician prescribed therapeutic diet for one of five residents reviewed for nutrition (Resident 156). Findings include: Review of facility policy, titled Therapeutic Diets, last revised December 2020, revealed it was the facility's policy that, Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Review of Resident 156's clinical record on December 11, 2023, at approximately 1:30 PM, revealed diagnoses that included end stage renal disease (kidneys cease to function) and diabetes mellitus type II (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 156's physician orders revealed a diet order for double portion entrée with meals, dated April 28, 2023. Review of Resident 156's meal tray ticket labeled for the lunch meal…

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, and staff interview, it was determined that the facility failed to ensure that it was free from a medication error rate of five percent or greater based on two medication errors out of 38 opportunities. Findings Include: Observation of medication administration on December 12, 2023, at 8:30 AM, revealed Employee 1 (Licensed Practical Nurse) administering Trelegy Ellipta Inhaler 200-62.5-25 inhaler to Resident 42. Review of Resident 42's physician orders revealed an order for Trelegy Ellipta Inhaler 200-62.5-25 (an inhaled medication) inhale one puff orally one time a day for chronic obstructive pulmonary disease (COPD - a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations) with specific directions to rinse mouth and spit after administration. Employee 1 was not observed to provide Resident 42 with water or to instruct them to rinse and spit after the Trelegy inhaler was administered. Employee 1 administered Resident 42's pills after the inhaler was administered. Observation 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 facility policy, observations, and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to storage of staff personal items in a medication cart in one of three carts observed and the preparation and administration of medications to one of four Residents observed (Resident 42). Findings include: Review of facility policy, titled Administering Medications, with a last review date of March 28, 2023, revealed 22. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. During a medication cart observation conducted on the first floor nursing unit on December 12, 2023, at 10:52 AM, with Employee 3, it was observed that Employee 3 had their purse stored in the bottom left hand drawer of the medication cart. The purse was sitting on top of Resident medication inhalers. During an immediate interview with Employee 3, the Employee stated that they were paranoid and…

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

Based on observations, facility document review, and staff interviews, it was determined that the facility failed to provide a therapeutic diet (a meal plan that controls the intake of certain foods or nutrients) for the lunch meal on October 19, 2023, for seven of seven residents on the Renal Diet (Resident 1, 2, 3, 4, 5, 6, and 7). Findings include: Review of the meal extension sheets revealed that residents on the renal diet were to be served 4 ounces (unit of measure) of green beans instead of 4 ounces of collard greens. During meal tray line observations on October 19, 2023, between approximately 12:00 PM and 1:00 PM, revealed there were no green beans on the tray line. Observation of lunch meal tray line on October 19, 2023, at approximately 12:35 PM, revealed Resident 6 was not served a vegetable side. Observation of lunch meal tray line on October 19, 2023, at 12:56 PM, revealed Resident 2 was served collard greens. During an interview with Employee 2 (Dietary Manager) on October 19, 2023, at 1:39 PM, after completion of lunch meal service, when the surveyor inquired if…

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 the facility menu, and staff interview, it was determined that the facility failed to follow the menu by not serving the posted menu offering for one of one meal service observed (August 23, 2023; lunch meal). Findings include: Review of the facility's lunch menu planned for August 23, 2023, revealed the vegetable that was to be served with the lunch meal was carrots. Review of the meal extension sheets revealed that the lunch meal was to be served with 4 ounces of carrots. During meal tray line observations on August 23, 2023, between approximately 11:00 AM and 1:50 PM, revealed that the lunch vegetable alternative to carrots was green beans. Observations of lunch meal tray line on August 23, 2023, revealed that, at approximately 1:30 PM, the facility had run out of available carrots to serve residents and was replaced with peas. Further observation of lunch meal tray line revealed 35 residents received peas instead of carrots as posted on the menu for the August 23, 2023, lunch meal. During a staff interview on August 24, 2023, the findings 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 observation, review of facility policy, and staff interviews, it was determined that the facility failed to provide food that is palatable and at a safe and appetizing temperature for one of one meal observed (August 23, 2023; 200 hallway). Findings include: Review of facility policy, titled Food Temperatures provided by Nursing Home Administrator (NHA) on August 23, 2023, at 3:18 PM, revealed in section 2 and 4 of Policy explanation and Compliance Guidelines stated, Hot foods will be held at 135 degrees Fahrenheit or greater .Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. Observations of food temperatures on August 23, 2023, at 2:03 PM, conducted by Employee 1 revealed the hot items of the meal were below 135 degrees Fahrenheit (F). The main course (beef goulash) temperature was 133.7 F; the vegetable (peas) temperature was 118.8 F. Furthermore, the cold items of the meal were above 41 degrees F: the gelatin dessert temperature was 49.6 F; and the temperature of the milk was 52.7 F. The food tray was tested at the time the last…

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