LeTort Spring Nursing and Rehab LLC

Based on observations, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for three of 21 residents reviewed (Residents 16, 49, and 74).Findings include: Review of Resident 16's clinical record revealed diagnoses that included cognitive communication deficit (a group of disorders that affect a person's ability to communicate, which can cause difficulty with understanding or producing language and nonverbal communication skills, such as gestures and facial expressions) and metabolic encephalopathy (a change in how your brain works due to an underlying condition that can cause confusion, memory loss, and loss of consciousness). Review of Resident 16's physician orders revealed an order for a wanderguard bracelet to left lower extremity, night shift to check every shift for function and every shift to check proper placement, dated February 3, 2026. Observations of Resident 16 on February 8, 2026, at 12:35 PM, and February 9, at 9:14 AM, revealed that his…

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

Based on policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to provide necessary services to carry out activities of daily living to maintain good nutrition and personal hygiene for residents' dependent on staff for assistance for two of 21 residents reviewed (Residents 5 and 12).Findings include:Review of the facility policy, titled Activities of Daily Living (ADLs), Supporting with a last revised and review date of April 24, 2025, revealed, 5. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting); d. dining (eating, including meals and snacks).Review of Resident 5's clinical record revealed diagnoses that included hypertension (high blood pressure) and major depressive disorder (a mental…

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 address weight loss in a timely manner for one of four residents reviewed (Resident 1).Findings include: Review of facility policy, titled Weight Assessment and Intervention, dated March 2022, revealed, in part, 3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietitian in writing. 4. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight)/(usual weight) x 100]: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10%…

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

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of one residents reviewed for tube feeding (Resident 75). Findings include:Review of the facility policy, titled Enteral Tube Feeding via Continuous Pump with a last revised date of November 2018, and a last review date of April 24, 2025, revealed, Initiate Feeding; 5. On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order.Review of Resident 75's clinical record revealed diagnoses that included diabetes (a condition that happens when your blood sugar is too high) and hemiplegia (the severe or complete paralysis of one side of the body, caused by brain or spinal cord damage).Observation of Resident 75 on February 9, 2026, at 9:39 AM, revealed that the Resident's feeding pump had been idle for 10 minutes and the pump had been inactive. Further review revealed that the bottle of…

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

Based on observations, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that respiratory care and services provided were consistent with professional standards of care for two of two residents reviewed for respiratory care (Residents 8 and 89). Findings Include:Review of facility policy, titled Oxygen Therapy revised April 24, 2025, revealed, Policy: A physician must order the oxygen therapy. 1. Verify that there is a physician's order for this procedure.Review of Resident 8's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (lung and airway disease that restricts breathing) and protein-calorie malnutrition (inadequate intake of protein and calories).During an interview with Resident 8 on February 8, 2026, at 10:38 AM, an observation was made of Resident 8 receiving supplemental oxygen via nasal cannula at 2 liters (of oxygen) per minute.An additional observation was made on February 9, 2026, at 11:20 AM, of Resident 8 receiving supplemental oxygen via nasal…

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

Based on review of facility policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that the residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of one residents reviewed (Resident 10). Findings Include:Review of facility policy, titled Trauma Informed Care and Culturally Competent Care, revised April 22, 2025, revealed, Purpose to address the needs of trauma survivors by minimizing and/or re-traumatization. Resident Assessment 1. Assessment involves an in-depth process of evaluation the presence of symptoms, their relationship to trauma, as well as identification of triggers.Review of Resident 10's clinical record revealed diagnoses that included post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. The condition may last months or years, with…

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

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to implement the licensed pharmacist's recommendations for one of five residents reviewed for unnecessary medications (Resident 7).Findings Include:Review of facility policy, titled Medication Regimen Review (Monthly Report), last revised April 22, 2025, revealed G. Recommendations are acted upon and documented by the facility staff and or the prescriber.Review of Resident 7's clinical record revealed diagnoses that included bipolar II disorder (mental health disorder with depressive episodes alternating with hypomanic episodes) and major depressive disorder (persistent feelings of intense sadness, worthlessness, and loss of interest in activities).Review of Resident 7's physician orders revealed the following orders: olanzapine (Zyprexa) antipsychotic medication) at bedtime for behaviors/mood and pantoprazole sodium (protonix one time a day).Review of Resident 7's monthly December medication review revealed that on December 28, 2025 a pharmacy recommendation…

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, staff interview, and observations, 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 29 opportunities.Findings include: Review of facility policy, titled Specific Medication Administration Procedures IIB6: Eye Drop Administration, undated, revealed, in part, Wait at least five (5) minutes before applying additional medication to the eye. Observation of medication administration on February 10, 2025, at 9:19 AM, Employee 3 (Licensed Practical Nurse [LPN]) was observed administering Resident 10 sucralfate 1000 MG (1 gram) oral tablet. Medication packaging indicated that the medication was to be administered before meals and at bedtime. During an immediate staff interview with Employee 3, she confirmed that Resident 10 had already completed her breakfast. Employee 3 indicated that she was running behind and that Resident 10's medication was not given as ordered. Observation of medication administration on February 10, 2025, at 10:40 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 clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to document a physician order for hospice services for one of one resident reviewed for hospice services (Resident 8).Findings Include:Review of the facility policy, titled Hospice Program, last reviewed April 22, 2025, failed to reveal that a physician order must be obtained for hospice services.Review of the clinical record for Resident 8 revealed clinical diagnoses that included chronic obstructive pulmonary disease (progressive irreversible lung disease causing chronic coughing, wheezing, and severe shortness of breath) and protein-calorie malnutrition (severe nutritional deficiency from inadequate intake of protein, calories, or both).Review of Resident 8's Significant change Minimum Date Set (MDS-periodic assessment and care screening) dated December 19, 2025, Section O- Special Treatments, Procedures and Programs, of the MDS indicated that Resident 8 was receiving hospice services.Review of Resident 8's physician orders failed to reveal an order 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 record review and staff interview, it was determined that the facility failed to prevent accident and hazards for one of 10 residents reviewed (Resident 2). Findings include: Review of Resident 2's clinical record revealed diagnoses that included dementia (a progressive cognitive and mental decline that is severe enough to interfere with daily life, affecting memory, thinking, language, and judgment) and hypertension (high blood pressure).Review of Resident 2's clinical record revealed a fall incident report where the resident had an unwitnessed fall on November 10, 2025, at 7:10 PM, onto the floor in the Love 2 Lounge and was found sitting in a semi-Fowler's position directly in front of her wheelchair. Further review of the incident report revealed there were no predisposing environmental factors noted during the fall. Further review of the fall incident report revealed an employee witness statement (Employee 1) revealed that Resident 2 went into the dayroom for dinner and was brought back to the dining room on Love and was last seen by Employee 1 at 5:45 PM at the dining…

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

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide adaptive feeding devices for one of 10 residents reviewed (Resident 1).Findings include:Review of Resident 1's clinical record revealed diagnoses that included dementia (a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities) and heart failure (when the heart muscle doesn't pump blood as well as it should).Review of Resident 1's physician orders revealed an order to make sure the Resident has a water cup filled and food is being cut up at mealtimes, dated December 4, 2025, as well as an order for the Resident to have foam handled utensils for all meals, dated June 10, 2024.Review of Resident 1's care plan revealed a nutritional care plan focus area with an intervention to provide adaptive equipment as ordered, date initiated on May 22, 2024, and revised on April 1, 2025.Observation of Resident 1 on December 22, 2025, at approximately 12:15 PM, revealed he was eating lunch in the dining room and did 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 staff interviews, it was determined that the facility failed to provide a notice of transfer for two of six residents reviewed for hospitalization (Residents 28 and 53 ), and failed to provide five of six residents reviewed for transfers with a notice of transfer that included the required information (Residents 1, 28, 52, 58, and 69). Findings include: Review of Resident 1's clinical record revealed diagnoses that included heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and hyperlipidemia (high fat levels in the blood). Review of Resident 1's clinical record revealed that on January 1, 2025, Resident 1 was transferred to the hospital due to an acute medical change in condition. Review of facility document, Notice of Resident Transfer or Discharge, provided to Resident 1's Representative, revealed the notice did not contain the mailing…

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 provide a copy of the facility's bed-hold notice upon transfer or discharge from the facility for two of six residents reviewed for transfer or discharge (Residents 28 and 53), and failed to provide bed-hold notices that included the required information for five of six residents reviewed for transfer or discharge (Residents 1, 28, 52, 58, and 69). Findings include: Review of Resident 1's clinical record revealed diagnoses that included heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and hyperlipidemia (high fat levels in the blood). Review of Resident 1's clinical record revealed that the Resident had been transferred and admitted to the hospital on [DATE]. Review of Resident 1's Bed Hold Prior to Transfer forms signed by their Representative for their January 1, 2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the residents right to participate in the care planning process for one of 18 resident's reviewed (Resident 4), and the facility failed to review and revise the resident plan of care for three of 18 residents reviewed (Residents 28, 37, and 58). Findings include: Review of facility policy, titled Comprehensive Care Plans with a last revised date of October 23, 2022, and a last review date of January 17, 2025, revealed, in part, 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Review of facility policy, titled Care Plan Revisions Upon Status Change, with a 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.

Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed to adequately monitor possible side effects and target behaviors for two of five residents reviewed for unnecessary psychotropic medications (Residents 53 and 58). Findings include: Review of facility policy, titled Psychoactive Medication Policy, last reviewed January 17, 2025, revealed subsection Psychoactive Medication Monitoring, stated, 'Monitoring' is the ongoing collection and analysis of information and comparison to resident baseline in order to [sic] [a]scertain the resident's response to treatment and care, including progress or lack of progress toward therapeutic goal[;] [d]etect complications or adverse consequences of the condition or of the treatments[; and,] [s]upport decisions to modify, discontinue, or continue any interventions. Further review of the aforementioned policy revealed subsection, titled Psychoactive Medication Monitoring Procedure, revealed it stated, Behavior Management Flow Records (BMFR) will be utilize to record and monitor the number…

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 interviews, it was determined that the facility failed to utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen. Findings include: Review of the forms, titled Dish Machine Temperature Log, utilized by the kitchen, read, in part, Keep temperature log on file for 1 year. Record Temperatures once per meal period. Review of the May 2024 Dish Machine Temperature Log revealed dish machine temperatures failed to be recorded on May 10, 14-17, 28, 30, and 31 at breakfast; May 7-18, 27, 28, 30, and 31 at lunch; and May 1-31 at dinner. June and July 2024 Dish Machine Temperature Logs failed to be provided. Review of the August 2024 Dish Machine Temperature Log revealed dish machine temperatures failed to be recorded on August 10 and 14 at lunch; and August 1-31 at dinner. Review of the September 2024 Dish Machine Temperature Log revealed dish machine temperatures failed to be recorded on September 1-30 at dinner. Review of the October 2024 Dish Machine Temperature Log revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 30 residents reviewed (Residents 17, 28, and 58). Findings include: Review of Resident 17's clinical record revealed diagnoses that included vascular dementia (a type of dementia caused by brain damage from impaired blood flow marked by memory disorders, personality changes, and impaired reasoning), dysphagia (difficulty swallowing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 17's clinical record revealed he had a significant weight loss of 31 pounds (-11.5%) from May 10, 2024, to November 4, 2024. Review of Resident 17's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last…

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

Based on observation, policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services to promote healing and prevent infection in accordance with professional standards for one of two residents reviewed for pressure ulcers (Resident 2). Findings include: Review of facility policy, titled Enhanced Barrier Precautions, last reviewed January 17, 2025, revealed the facility's policy stated, It is the policy of the this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Review of the aforementioned policy revealed section 2. Initiation of Enhanced Barrier Precautions, subsection b stated, An order for enhanced barrier precautions will be obtained for residents with any of the following .Wounds (e.g., chronic wounds such as pressure ulcers .even if the resident is not known to be infected or colonized with a [multi-drug resistant organism. Section 3, Implementation of Enhanced Barrier Precautions, subsection a stated, Make gowns and gloves available…

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, observation, and staff interviews, it was determined that the facility failed to prevent accident and hazards for two of 18 residents reviewed (Residents 35 and 47.) Findings include: Review of Resident 35's clinical record revealed diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks) and hyperlipidemia (high levels of fats in the bloodstream). Review of Resident 35's fall incident report that occurred on September 8, 2024, revealed Resident 35 had an un-witnessed fall that occurred in the Resident's bathroom. The Incident Description revealed, in part, This writer was called to residents' room related to unwitnessed fall in bathroom. [NAME] noted to foot of bed in residents' room. Bathroom call bell was not activated. Staff reports assisting resident to the bathroom and providing her with the call bell prior to fall. No staff member present in the bathroom when resident attempted to get herself off the toilet. No apparent injuries noted.…

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, resident and staff interviews, and facility document review, it was determined that the facility failed to ensure residents are assisted with obtaining routine dental care for one of one residents reviewed for dental care (Resident 52). Findings include: Review of Resident 52's clinical record on February 3, 2025, revealed diagnoses that included hypertension (elevated/high blood pressure) and diabetes mellitus type two (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment). During a resident interview on February 3, 2025, Resident 52 indicated that he was awaiting teeth extraction of his upper teeth in order to have a full-upper denture created. During the interview, Resident 52 stated that he had a partial top denture that moves around as he eats. Review of Resident 52's clinical record revealed a dental consultation that was conducted on October 21, 2024. Review of the dental consultation sheet revealed that section Treatment notes, stated, [Patient] wears upper partial…

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

Based on observations, facility policy review, and staff interviews, it was determined that the facility failed to ensure staff implemented infection control policies to prevent the spread of infection by using PPE (personal protective equipment) in two of four resident care areas reviewed (Love one and Love two), and failed to handle potentially contaminated items to decrease the possibility for transmission of a infectious disease for one of one unit treatment carts observed (Love unit treatment cart). Findings Include: Review of facility policy, Transmission-Based (Isolation) Precautions, last reviewed January 17, 2025, revealed that, Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Further review of this policy under the section labeled, Contact Precautions, revealed that healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or…

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 provide evidence that education was provided to Residents and/or their Representatives on the risks, benefits, or side effects of the influenza vaccine for two of five residents reviewed for immunizations (Residents 8 and 25). Findings Include: Review of facility policy, titled Influenza Vaccination with an implementation date of April 7, 2022, and a last review date of January 17, 2025, revealed, in part, 5. Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of CDC's current vaccine information statement relative to the influenza vaccination. 6. The vaccine information statements (VIS) will, as appropriate, be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding the benefits and potential side effects of the influenza vaccine. (See Vaccine Information Statements Policy.) 7. Individuals receiving 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 provide evidence that education was provided to Residents and/or their Representatives on the risks, benefits, or side effects of the COVID-19 vaccine for two of five residents reviewed for immunizations (Residents 8 and 25). Findings Include: Review of facility policy, titled COVID-19 Vaccination with a last revised date of June 19, 2023, and a last review date of January 17, 2025, revealed 26. The resident's medical record will include documentation of the following: a. Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine; b. Each dose of the vaccine administered to the resident, or c. If the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal. Review of Resident 8's clinical record revealed diagnoses that included hypertension (high blood pressure), diabetes (disease that occurs when your blood glucose, also called blood sugar, is too…

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

Based on clinical record review, review of Centers for Disease Control and Prevention guidance, facility documentation review, and staff interviews, it was determined that the facility failed to implement infection control practices to prevent or limit the spread of infectious disease for 13 of 17 residents reviewed for skin conditions (Residents 2, 4, 5, 7, 8, 9, 10, 11, 13, 14, 15, 16, and 17). Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance, titled Public Health Strategies for Scabies Outbreaks in Institutional Settings, dated December 18, 2023, revealed the guidance stated: Prevention: Early detection, treatment, and implementation of appropriate isolation and infection control practices are essential in preventing scabies outbreaks. Institutions should maintain a high index of suspicion that undiagnosed skin rashes and conditions may be scabies, even if characteristic signs or symptoms of scabies are absent (e.g. no itching). New patients/residents and employees should be screened carefully and evaluated for any skin conditions that…

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

Based on clinical record review, observation, policy review, staff interview, and facility document review, the facility failed to protect the resident's right to be free from physical abuse by a staff member for one of three residents reviewed for abuse (Resident 1). Findings include: Review of facility policy, titled Abuse, Neglect and Exploitation, last revised June 23, 2024, revealed the statement, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Review of Resident 1's clinical record revealed diagnoses that included dementia (irreversible, progressive degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and hypertensive heart disease (group of heart conditions caused by chronic high blood pressure). Review of facility incident report completed by Employee 2 (Registered…

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, staff interviews, and facility document review, it was determined that the facility failed to provide care and services in accordance with professional standards of practice for one of 18 residents reviewed for skin issues (Resident 18). Findings include: Review of Resident 18's clinical record revealed diagnoses that included dementia (irreversible, progressive degenerative brain disease that results in decreased contact with reality and decreased ability to perform activities of daily living) and hypertension (elevated/high blood pressure). Further, review of Resident 18's clinical record revealed that on October 15, 2024, a physician communication form stated, Resident [18's] family [complaint of] rash like areas on [right] arm. The physician responded with an order for hydrocortisone cream 1% twice a day as needed. At 4:00 PM, a interdisciplinary note was entered which stated, POA [Power of Attorney] (son) made aware of new order for hydrocortisone cream [due to] [bilateral upper extremity] rash. POA voiced concern for possible need bath soap…

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 timely notify hospice of a change in condition for one of six residents reviewed (Resident 1). Findings Include: Review of facility policy, titled Notification of Changes, revised August 29, 2023, revealed, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: .Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. Review of the facility's hospice contract with Resident 1's hospice provider, most recently dated August 26, 2013, revealed Facility shall immediately notify Hospice when: a. A significant change in a patient's physical, mental, social or emotional status occurs. b. Clinical complications appear that suggest the need to alter the plan of care. The contract also stated, in part,…

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 and staff interview, it was determined that the facility failed to develop a Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella, a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia). Findings Include: Review of facility policy, titled Water Management Program, dated October 23, 2022, revealed It is the policy of this facility to establish water management plans for reducing the risk of Legionellosis and other opportunistic pathogens . A water management team has been established to develop and implement the facility's water management program . The Maintenance Director maintains documentation that describes the facility's water system . A risk assessment will be conducted by the water management team annually . The facility was unable to provide an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread, and was unable to provide evidence of measures to prevent the growth of opportunistic waterborne pathogens 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 reviews, and staff interviews, it was determined that the facility failed to ensure that services were provided with reasonable accommodation of resident need for one of 17 residents reviewed (Resident 6). Findings include: Review of Resident 6's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), legal blindness (a term to describe severe visual impairment that cannot be corrected with glasses or contact lenses), and generalized anxiety disorder (a mental disorder characterized by feelings of worry, nervousness, or unease). Review of Resident 6's care plan revealed a focus area of [Resident 6] has impaired visual function related to legal Blindness ., created on February 23, 2023, with interventions for Place foods in individual bowl except sandwiches, arrange all items on tray, by placing same arrangement on tray each time to enhance ability to feed self created on February 23, 2023, and The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for six of 19 residents reviewed (Residents 6, 7, 8, 22, 33, and 41). Findings Include: Review of Resident 6's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), legal blindness (a term to describe severe visual impairment that cannot be corrected with glasses or contact lenses), and generalized anxiety disorder (a mental disorder characterized by feelings of worry, nervousness, or unease). Review of Resident 6's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) dated February 23, 2024, revealed under Section O. Special Treatments, Procedures and Programs, subsection K1.…

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, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident's comprehensive plan of care was updated upon changes in the resident's condition for three of 17 residents reviewed (Residents 29, 53, and 60). Findings Include: Review of facility policy, titled Care Plan Revisions Upon Status Change, with a last revised date of April 18, 2023, revealed 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Review of Resident 29's clinical record revealed diagnoses that included atrial fibrillation (A-fib- an irregular, often rapid heart rate that commonly causes poor blood flow) and hypertension (elevated blood pressure). Review of Resident 29's current care plan revealed an active care plan for a pressure ulcer, dated December 10, 2023. Review of Resident 29's wound assessment dated [DATE], revealed that Resident 29's pressure ulcer resolved as of this…

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, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for four of 19 residents reviewed (Residents 7, 22, 45, and 67). Findings Include: Review of facility policy, titled Dressing Change Policy, dated January 15, 2017, revealed Remove soiled dressing and discard in a trash bag; .Don non-sterile/sterile gloves (when appropriate) prior to cleansing wound site; Cleanse wound site per physician's order; Wash hands; [NAME] non-sterile/sterile gloves (when appropriate) and apply topical treatment as ordered . Review of facility policy, titled Pressure Injury Prevention and Management, dated October 23, 2022, revealed Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device.…

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 consult qualified dietary staff to assess the nutritional needs of residents in the absence of a qualified dietitian for four of 17 residents reviewed (Residents 22, 23, 45, 57). Findings include: During the initial tour of the kitchen and pantries with Employee 9 (Cook) on Monday March 18, 2024, at 9:25 AM, he revealed the Dietary Manager was off that day, the Dietitian was new, and he wasn't sure about her schedule. During an interview with the Nursing Home Administrator (NHA) on March 20, 2024, at 10:50 AM, she revealed they now have a Dietitian that recently started a little over a week ago. During an interview with Employee 8 (Dietary Manager) on March 20, 2024, at 11:25 AM, he revealed he has been employed as the Dietary Manager at the facility since October 2023 and they have been without a Dietitian since then. He revealed nursing communicates residents' diet orders to the kitchen, and Employee 9, himself, or a dining clerk see residents upon admission, and as needed, 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 facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and utilize and monitor equipment in accordance with professional standards for food service safety in the main kitchen and in two of two pantry areas. Findings include: Review of facility policy, titled Date Marking for Food Safety, last revised April 15, 2023, read, in part, Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food .refrigerated, ready-to-eat, time/temperature control for safety food (i.e. perishable food) shall be held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days .The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded .the marking system shall consist of the day/date of opening and the day/date the item must be consumed or discarded .the department head, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard them…

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 personnel file review and staff interviews, it was determined that the facility failed to ensure each nurse aide was provided required in-service training consisting of no less than 12 hours per year, which included dementia management and resident abuse prevention, for five of five nurse aide employee records reviewed (Employees 2, 3, 4, 5, and 6). Findings Include: Review of personnel information revealed Employee 2's hire date was February 14, 2022; Employee 3's hire date was May 2, 2016; Employee 4's hire date was June 21, 2022; Employee 5's hire date was September 4, 2012; and Employee 6's hire date was September 18, 2017. Review of facility training records failed to reveal that the aforementioned Employees completed 12 hours of required annual training in the past 12 months. Further review of facility training records failed to reveal evidence that dementia management training was completed by Employees 2, 3, 4, 5, and 6 within the past 12 months, or that abuse prevention training was completed by Employee 3 within the past 12 months. During an interview with the…

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

Based on clinical record review and staff interview, it was determined the facility failed to develop a discharge summary that anticipated resident needs and included all required information for one of two discharged residents reviewed (Resident 69). Findings Include: Review of Resident 69's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 69's clinical record revealed she was discharged to her home on December 23, 2023. Continued review of Resident 69's clinical record revealed no documentation of a recapitulation of the resident's stay, a final summary of the resident's status, a reconciliation of the resident's pre-discharge and post-discharge medications, or a post-discharge plan of care, developed with resident participation, to assist Resident 69 to adjust to her living…

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 resident and staff interviews, it was determined that the facility failed to provide assistance with activities of daily living (ADL) for dependent residents for one of 19 residents reviewed (Resident 29). Findings Include: Review of facility policy, titled Activities of Daily Living, dated November 26, 2016, revealed The facility will provide care and services for the following activities of daily living: (1) Hygiene- bathing, dressing, grooming and oral care. Review of Resident 29's clinical record revealed diagnoses that included atrial fibrillation (A-fib- an irregular, often rapid heart rate that commonly causes poor blood flow) and hypertension (elevated blood pressure). Review of Resident 29's current ADL care plan, dated December 10, 2023, revealed that Resident 29 is a moderate 1-2 assist for dressing. Further review of Resident 29's care plan revealed no evidence that Resident 29 prefers to stay in bed or prefers to be in a gown. Observation of Resident 29 on March 18, 2024, at 12:13 PM and 1:00 PM,…

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

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to implement a fall intervention for one of six residents reviewed for falls (Resident 29). Findings Include: Review of facility policy, titled Fall Prevention and Management Interventions, dated May 11, 2018, revealed Bedside mat. Review of Resident 29's clinical record revealed diagnoses that included atrial fibrillation (A-fib- an irregular, often rapid heart rate that commonly causes poor blood flow) and hypertension (elevated blood pressure). Review of Resident 29's progress notes revealed a note dated January 22, 2024, stating that Resident 29 had an unwitnessed fall and a new fall intervention would be a fall mat to the left side of Resident 29's bed. Review of Resident 29's current care plan revealed an intervention dated January 22, 2024, for a fall mat to the left side of the bed. Review of Resident 29's current physician orders revealed an order dated February 8, 2024, for a fall mat to the left side of the bed. Observations 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, clinical record reviews, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for two of two residents reviewed for respiratory care (Residents 33 and 41). Findings Include: Review of facility policy, titled Noninvasive Ventilation (CPAP [in part]), with an implemented date of April 17, 2023, revealed Definitions: CPAP, or continuous positive airway pressure, is a respiratory therapy intervention used to provide a patent airway during periods of sleep apnea [intermittent airflow blockage during sleep]. It uses air pressure generated by a machine, delivered through a tube into a mask that fits over the nose or mouth and 13. Follow manufacturer instructions for the frequency of cleaning/replacing filters [in part]. Review of Resident 33's clinical record revealed diagnoses that included sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts) and atrial fibrillation (A-fib - an irregular,…

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

Based on observations, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure there was sufficient staff to ensure residents attained or maintained the highest practicable physical, mental, and psychosocial well-being for one of 19 residents reviewed (Resident 29). Findings Include: Review of facility policy, titled Call Lights: Accessibility and Timely Response, dated October 23, 2022, revealed All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. Review of Resident 29's clinical record revealed diagnoses that included atrial fibrillation (A-fib- an irregular, often rapid heart rate that commonly causes poor blood flow) and hypertension (elevated blood pressure). Review of Resident 29's current care plan revealed an intervention, dated December 10, 2023, for moderate assistance with toilet use, and a care plan intervention, dated February 6, 2024, to transfer…

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

Based on facility document review and staff interview, it was determined that the facility failed to complete a performance review for nurse aide staff at least once every 12 months for one of five employees reviewed (Employee 6). Findings Include: Review of Employee 6's personnel record revealed a hire date of September 18, 2017, and no evidence of a recent annual performance review. On March 20, 2024, at 8:22 AM, the Nursing Home Administrator confirmed that Employee 6 did not have a recent annual performance review completed. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.19(2) Personnel policies and procedures.

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 an accurate accounting of the disposition of uncontrolled medications during the discharge process for one of two discharged residents reviewed (Resident 68). Findings include: Review of Resident 68's closed clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations) and chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats causing the heart to be unable to pump an adequate amount of blood to the body). The review of the closed clinical record for Resident 68 on March 21, 2024, revealed that Resident 68 was admitted to the facility on [DATE], and that they passed away at the facility on January 9, 2024. Review of Resident 68's physician orders revealed that the resident had a total of 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the physician reviewed and responded to pharmacy review recommendations in a timely manner for one of five residents reviewed for unnecessary medications (Resident 7). Findings include: Review of facility policy, titled Medication Regimen Review, undated, revealed At least monthly, the consultant pharmacist reports any irregularities to the attending physician, Medical Director and Director of Nursing .The findings are faxed or e-mailed within (72 hours) to the director of nursing or designee and are documented in the resident's active record. The prescriber and/or medical director is notified if needed .Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. Review of Resident 7's clinical record revealed diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from…

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

Based on facility policy review, review of select facility documentation, observation, completion of a test tray, and resident and staff interviews, it was determined that the facility failed to provide food and beverages that were palatable and at appetizing temperatures for one of one meals tested. Findings include: Review of facility policy, titled Resident Services- Taste and Temperature Control, last revised November 2002, read, in part, Cold foods such as milk, butter, ice cream and juices are refrigerated during service or properly iced. Review of document, titled Senior Living Meal Assessment, revealed hot food should be served at 130 degrees or greater, and cold beverages should be served at or below 45 degrees. An interview with Resident 270 on March 18, 2024, at 10:54 AM, revealed the food could be better and is always served cold. Review of facility grievance log for November 2023 revealed a grievance filed on November 15, 2023, with complaints of cold food. Observation during the tray line meal service on March 20, 2024, at 11:50 AM, revealed the cold beverages served…

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.