Kadima Rehabilitation & Nursing At Cheswick

Based on review of facility policy and documents, and interviews with staff, it was determined that the facility staff failed to implement policies and procedures to notify the administrator and local law enforcement in a timely manner after a visitor/former employee entered the facility with a loaded handgun and discharged the handgun on one of three nursing units (Third Floor Nursing Unit).Findings include: Review of facility policy Abuse Protection dated 4/28/26, indicated our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, etc.; training is provided as time of hire, annually and as needed. The reporting and filing of accurate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to follow a physician order for one of four residents (Resident R1). Findings include: Review of facility policy Medication & Treatment Orders dated 4/28/26, indicated each medication administered will have a corresponding and complete physician's order. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included fracture, left femur, atrial fibrillation (irregular heart rhythm that originates in the heart's upper chambers) and malnutrition. Review of Resident R1s Medicare-5day MDS assessment (minimum data assessment)- periodic assessment of resident care needs) dated 4/27/26, indicated the diagnosis remained current. Review of Resident R1's most recent physician orders indicate Sodium Chloride Injection Solution 0.9 % (Sodium Chloride) Use 60 ml/hr intravenously every shift for AKI, hydration for 1 day, ordered on 4/28/26. Review of…

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

Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility by failing to create a safe environment free of accidents when a visitor/former employee entered the facility with a loaded handgun and discharged the handgun on the Third Floor Nursing Unit, which created an immediate jeopardy situation for all residents.Findings include: The job description for the Nursing Home Administrator specified the primary purpose of the job position is to manage the Facility with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities To follow all facility policies and apply them uniformly to all employees. The ensure the highest degree of quality care is provided to our residents at all times. The job description for the Director of Nursing specified the purpose of the job is to plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility documents, observations, and staff interviews, it was determined the facility failed to keep residents free from hazards and provide the necessary monitoring and supervision for residents with known suicidal ideation and history of a suicide attempt for two of three residents (Resident R1, and R2).Findings include: Review of facility policy Suicide Threats dated 11/1/25, indicated resident suicide threats must be taken seriously and immediately reported to the nurse supervisor charge nurse. A staff member must remain with the resident until the nurse supervisor/charge nurse arrives to examine the resident. The resident will be placed on 1:1 observation until the acute episode has been resolved if the resident is capable of self-injury. The resident shall remain on 1:1 monitoring until transfer from the facility for acute intervention or nursing assessment has identified the resident is no longer a safety risk. The charge nurse or designees shall…

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

Based on observation and staff interview, it was determined that the facility failed to record food temperatures at the time of service in the main kitchen. Findings include: A review of the facility's food temperature log on 3/4/26, at 12:15 p.m. revealed that there was no documented evidence that the holding food temperatures were obtained at the time of of during service for breakfast and lunch to ensure that the food maintained safe internal temperatures. In an interview during this observation period, Dietary Manager Employee E7 stated confirmed that there were no recorded temperatures for breakfast or lunch and they should have been recorded. 28 Pa. Code 201.14(a)Responsibility of licensee.28 Pa. Code 201.18(b)(3) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions and/or goals to address the care needs of residents for two of four residents reviewed (Resident R2 and R3). Findings include: Review of the facility policy MDS/RAI/Care Planning last reviewed on 11/1/25, indicated the care planning process provides a tool for an interdisciplinary approach to the care of the residents. The care plan will be assessed at least quarterly and reviewed by the interdisciplinary team. Review of the clinical record revealed that Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/21/26, indicated the diagnosis of diabetes (high sugar in the blood), anxiety and chronic pain. Review of Resident R2's physician orders dated 1/14/26, indicated Methadone (used to treat chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide the necessary services to maintain personal hygiene for one of four residents reviewed (Resident R5). Findings include: Review of facility policy, Flow of Care, dated 11/1/25, revealed care will be provided to residents, as needed 24-hour a day to attain and maintain the highest level of functioning. Clinical record review revealed Resident R5 was admitted to the facility on [DATE], with diagnosis to include, fibromyalgia (chronic disorder that cause widespread pain, fatigue and other symptoms), adult failure to thrive and diabetes mellitus. Review of physician orders dated 1/2/26 indicated showers to be given evening shift on Tuesday and Fridays. Review of Resident R5's bathing records from January 2026 indicated resident received two bed baths, 1/6/26 and 1/16/26, missing six showers. Interview with the Director of Nursing on March 4, 2026, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, and resident and staff interview, it was determined that the facility failed to procure complete physician's orders for two of three residents who receive outside services (Resident R2 and R3)Findings include: Review of the facility policy Transfer to Appointment Outside the Facility last reviewed 11/1/25, indicated verify that a physician order for appointment/consult is present. Arrange for transportation as appropriate. Arrange for escort as appropriate. Review of the clinical record revealed that Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/21/26, indicated the diagnosis of diabetes (high sugar in the blood), anxiety and chronic pain. Review of Resident R2's physician orders dated 1/14/26, indicated Methadone (used to treat chronic pain and opioid use disorder) HCl Oral Concentrate 10 milligrams/milliliter (MG/ML) give 8 ml by mouth two times a day for chronic…

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 records and facility policy review, and staff interview, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services for one of three residents (Resident R96).Based on clinical records and facility policy review, and staff interview, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services for one of three residents (Resident R96).Findings include: Review of facility policy Suicide Threats dated 11/24, indicated resident suicide threats must be taken seriously and immediately reported to the nurse supervisor charge nurse. A staff member must remain with the resident until the nurse supervisor/charge nurse arrives to examine the resident. A behavioral health professional consult is indicated whenever the resident suggests suicide. Review of the clinical record…

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

Based on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of four quarterly meetings (Quarter Three of 2025). Findings Include: The facility Quality Assurance/Performance Improvement policy dated 9/4/25, indicated the facility will conduct quality assurance/improvement and assessment committee meeting at least quarterly to identify areas of service that are non-complaint, or with potential for improvement. Review of Quality assurance and Performance Improvement sign in sheets and attendance records for Quarter Three of 2025, failed to reveal the Infection Preventionist, Director of Nursing, and Medical Director were in attendance. During an interview on 10/31/25, at 12:59 p.m. the Nursing Home Administrator confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of four…

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 a review of facility policies, observations and staff interviews it was determined that the facility failed to provide a safe, clean, comfortable environment for the residents in resident rooms [ROOM NUMBERS], Second floor dining room, and the Third floor dining room as required. (Resident room [ROOM NUMBER], Resident room [ROOM NUMBER], Second floor dining room, and Third floor dining room) Findings include: A review of facility policy Environmental Services, Clean, safe and Orderly Environment dated 3/21/25, revealed that the exterior and the interior of the facility will be maintained in clean, safe and orderly manner. Housekeeping, Laundry, and Maintenance services will be provided properly with precaution taken to prevent infection and cross contamination. During an observation on 7/2/25, conducted from 12:30 p.m., through 1:00 p.m., revealed the following: - room [ROOM NUMBER]'s air conditioning unit had a build-up of grime, and black debris on the air inlet grill and internal area immediately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for incident or accidents for two of six residents (Residents R1, R2). Findings include: The facility Accident and Incident-Investigating and Reporting policy dated 7/1/24, indicated all accidents or incidents occurring on the premises must be investigated and reported to the administrator. Review of clinical record indicated Resident R2 was admitted [DATE], with diagnoses which included anxiety, diabetes mellitus and bipolar disorder. A review of Resident R2's Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 3/5/25, indicated diagnoses remained current. Review of Resident R2 nurse progress notes dated 4/17/25 Resident R2 was reported that on 4/13/25, resident was observed in the basement near the kitchen. When interviewed Resident R2 (BIMS score 15/15) stated that she did go to the basement to seek kitchen staff regarding her…

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 a review of facility policies, Four week Spring Summer (SS) cycle menu diet extension sheets and staff interviews it was determined that the facility failed to review, date. approve, and follow a preplanned cycle menu (Four week Spring Summer cycle menu, lunch meal on 3/19/25) as required. Findings include: A review of facility Menu policy dated 8/5/24, revealed that standardized cycle menus are prepared by the corporate menu team and fulfill residents' nutritional and therapeutic needs. The faciliy Registered Dietician reviews and approves the menu. A review of the facility's Four Week Spring Summer Cycle Menu extension spreadsheets provided by the facility revealed that the menus failed to provide documented evidence that the facility's Registered Dietician (RD) reviewed, dated and approved the four week Spring Summer cycle menu. During an interview on 3/19/25, at 11:45 am Food Service Director Employee E5 confirmed that the facility implemented the four week Spring Summer cycle menu prior to his hiring in 11/24. During an observation of the lunch meal service on 3/19/25,…

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 a review of facility policies, observations and staff interviews it was determined that the facility failed to provide a safe, clean, comfortable environment for the residents in residnet room [ROOM NUMBER], First floor common area, and the elevator door on the second floor nursing unit as required. ( Resident room [ROOM NUMBER], First floor common area, elevator door second floor nursing unit) Findings include: A review of facility Resident Environment policy dated 7/1/24, revealed that the facility will maintain a safe, clean and comfortable homelike environment for the residents. During an observation on 3/19/25, it was revealed the following: * the door jam at the elevator door on the second floor nursing unit was missing on the right side side which exposed rough and unfinished plaster which created an unsafe environment for the residents, * there was torn and missing wall paper on the wall in the lounge area on the first floor * Resident room [ROOM NUMBER] contained peeling and chipping paint 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 a review of facility policies, manufacture instructions, observations and staff interviews it was determined that the facility failed to follow manufacture instructions for the production of sugar free pudding on 3/19/25. (sugar free pudding) Findings include: A review of facility Standardize Recipes policy date 8/5/24, it was revealed that standardized recipes are used in the production of food products. During an interview on 3/19/25, at 10:30 am Food Service Worker Employee E3 confirmed that tray line service for the lunch meal begins at 11:00 am. She further confirmed that the production sheets indicated 33 servings of diet (sugar free) pudding was needed for the lunch meal service. During an observation on 3/19/25, at 10:30 am it was revealed that the facility failed to prepare 33 serving of diet (sugar free) pudding needed for the lunch meal service. During an observation on 3/19/25, at 10:35 am Food Service Worker Employee E2 was observed preparing diet (sugar free) pudding by pouring two quarts of 2% milk onto a mixing bowl and adding two packets of sugar free…

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 a review of facility policies, observations, resident tray cards, menu diet extension sheets, and staff interviews it was determined that the facility failed to provide the approved dessert for 23 of 23 residents prescribed a Mechanical Soft diet and nine out of nine resident prescribed a puree diet for the lunch meal service on 3/19/25. Findings include: A review of facility Menu policy dated 8/5/24, revealed that standardized cycle menus are prepared by the corporate menu team and fulfill residents' nutritional and therapeutic needs. The faciliy Registered Dietician reviews and approves the menu. A review of facility Description of Standard Diets policy date 8/5/24, revealed that a mechanical diet is used when a resident has difficulty chewing and or swallowing. A puree diet is used for residents that have difficulty chewing or swallowing, the food consistency is pureed. During a review of the resident's tray cards for the lunch meal on 3/19/25, it was revealed that for dessert the resident prescribed a mechanical soft diet were to receive a mechanical soft lemon…

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 clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for three of seven residents (Resident R1. R2 and R3). Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/29/25, indicated diagnoses of alcoholic cirrhosis of liver, chronic kidney disease and hepatic encephalopathy(condition where the brain becomes impaired due to severe liver disease). Review of Resident R1's clinical record revealed social services did not do an initial admission assessment. Review of Resident R2's admission record indicated the resident was admitted to the facility 1/29/25. A review of Resident R2's MDS dated [DATE], included diagnoses of orthopedic aftercare, absence of left leg below knee and alcohol-induced chronic pancreatitis. Review of Resident…

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

Based on a review of facility policies, documents and staff interviews it was determined that the facility failed to secure a surety bond on behalf of the residents of the facility that assured the security of all personal funds of residents deposited with the facility for three months 11/24, 12/24, and 1/25 as required. (11/24, 12/24, and 1/25) Finding include: A review of facility Surety Bond policy dated 7/1/24, indicated that a surety bond is purchased on behalf of the residents by the facility to protect the financial security of resident's funds deposited in a resident trust account. The facility evaluates the value of the bond annually to make certain that sufficient coverage is maintained. A review of the facility's Resident Trust Surety Bond effective 11/1/24, revealed that the bond's value at $193,915.84, A review of the Facillity Trial Balance (a document providing evidence of each resident's current balance held by the facility) date 1/7/25, indicated the value of funds held by the facility at $252,107.96 During an interview on 1/7/25, at 1:00 pm the Nursing Home…

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

Based on review of clinical records and staff interview, it was determined that the facility failed to ensure that a Speech Therapist who provided care to residents was licensed as a Speech Therapist for three of 12 months (November, and December 2024, and January 2025) Findings include: Review of Title 49 Chapter 45 indicated that Speech Therapists on a provisional license shall practice only under supervision of a supervisor who holds the same type of license as the provisional licensee, who is physically present in the area or unit where the provisional licensee is practicing. During an interview on 1/7/25, at 11:09 a.m. Speech Language Pathologist (SLP) Employee E2 confirmed that she has a provisional speech therapist license, as she is required to complete nine months of a fellowship before she will be issued a regular license. SLP Employee E2 stated that she had been supervised by a licensed SLP on a daily basis, however this stopped on 11/10/24 when the licensed SLP terminated her employment at the facility. Since 11/10/24, SLP Employee E2 has been working without daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by maintaining an acceptable temperature range throughout resident areas for 32 resident rooms on three of three units (First, Second, and Third Floor). Findings Include: Review of the facility policy Resident Environment dated 7/1/24, indicated the facility will provide an environment that is safe, clean, comfortable, and homelike. A homelike environment de-emphasizes the institutional character of the setting. Review of the facility policy Temperature Extremes dated 7/1/24, indicated the facility is to provide comfortable and safe temperature levels. The temperature throughout the facility shall be maintained at between 70 degrees and 82 degrees Fahrenheit (F). Review of Title 42 Code of Federal Regulations 483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990, must maintain a…

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

Based on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility. Findings include: A review of facility policy Sanitation dated 7/1/24, indicated the food service area shall be maintained in a clean and sanitary manner. All equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas. During an observation on 11/4/24, at 9:50 a.m., of the walk-in cooler in the main kitchen, conducted with Food Service Director (FSD) Employee E3, revealed that the cold air condenser fan covers had a build-up of dust, grime, and dark colored debris. FSD Employee E3 confirmed observation by surveyor when viewed. During an interview on 11/4/24, at 9:55 a.m., FSD Employee E3 confirmed that the facility failed to properly maintain kitchen equipment, walk-in cooler, in a sanitary condition creating the potential for cross contamination in the main…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four out of five residents sampled with facility-initiated transfer (Residents R41, R58, R69, R70). Findings include: Review of Resident R41's admission record indicated she was originally admitted on [DATE], with diagnoses that included neurocognitive disorder with muscle weakness, high blood pressure, and insomnia (difficulty falling or staying asleep). Review of Resident R41's clinical record revealed that the resident was transferred to the hospital on 9/28/24, and returned to the facility on 9/29/24. Review of Resident R41's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of five resident hospital transfers (Resident R58, R69, R70). Findings include: Review of Resident R58's admission record indicated she was originally admitted on [DATE], with diagnoses that included neurocognitive disorder with anxiety, high blood pressure, and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life.) Review of Resident R58's clinical record revealed that the resident was transferred to the hospital on 9/23/24, and returned to the facility on 9/28/24. Review of Resident R58's clinical record failed to include documented evidence that the resident or the resident's representative were provided…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for five of five residents (Resident R41, R43, R44, R59, and R77). Findings include: Review of facility policy Trauma Informed Care dated 7/1/24, indicated the facility will provide individualized and personalized care to the residents. Upon admission, screening for trauma will occur by the social worker. This information will be provided to the interdisciplinary team as needed, for care, treatment, and diagnosis. When information about past trauma becomes available the interdisciplinary team will incorporate this information into the resident's care. Review of the clinical record indicated Resident R41 was admitted to the facility on [DATE], and readmitted [DATE]. Review of the facility's Social Service History assessment dated [DATE], failed to assess…

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 a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a physician order for hospice services and to ensure the coordination of hospice services (supportive services for end stage terminal illness) with facility services to meet the needs of each resident for end-of-life care for three of three residents (Resident R18, R38, and R76). Findings include: Review of the facility policy Hospice Care dated 7/1/24, indicated all hospice assessments, plan of care, progress notes and services provided will be maintained on the medical record and integrated with the facility plan of care. Nursing staff will ensure there is a current physician's order, physician progress note regarding Hospice care, Hospice documentation is current and available on the medical record. Review of the admission record indicated Resident R18 admitted to the facility on [DATE]. Review of Resident R18's MDS, dated [DATE], indicated the diagnoses of Parkinson's Disease…

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 policies, clinical record review, observation, and staff interviews, it was determined the facility failed to ensure enhanced barrier precautions were ordered and implemented for four of four residents (Resident R26, R41, R44, and R65). Findings include: Review of facility policy Enhanced Barrier Precautions dated 7/1/24, indicated enhanced barrier precautions require the use of gown and gloves only for high-contact resident care activities. High contact resident care activities include device care or use of urinary catheter. It was indicated an enhanced barrier precaution sign is displayed near the entrance of the room or the facility has another system to communicate may be utilized to alert staff of the enhanced barrier precautions. PPE supplies will be available for use (gloves, gown) near the resident's room. A trash can will be placed near the exit of the resident room to dispose of gown and gloves. Review of Center for Disease (CDC) definition for Enhanced Barrier Precautions (EBP, a…

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

Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for two of three units (Second-floor, and Third-floor). Findings include: Review of the facility policy Resident Environment dated 7/1/24, indicated the facility will provide an environment that is safe, clean, comfortable, and homelike. A homelike environment de-emphasizes the institutional character of the setting. Observation on 11/4/24, at 9:35 a.m. Resident R44 had two square floor tiles missing from the right side of the bed. Observation on 11/4/24, at 11:42 a.m. the Second-floor dining room had seven trays stacked with old dishes from breakfast on the table against the far wall. There were five residents eating their lunch at this time. One mechanical lift, and two unused wheelchairs were stored in one corner of the dining room, and two additional unused wheelchairs in the opposite corner. Observation on 11/4/24, at 10:42 a.m. Resident R56 had multiple divots (small holes/depressions) in the floor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, facility documents, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain residents were free from neglect for one of three residents (Resident R53). Findings include: Review of facility policy Abuse: Protection From Abuse dated 7/1/24, indicated residents have the right to be free from neglect and abuse. Review of the admission record indicated Resident R53 admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident R53's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/23/24, indicated the diagnoses of anxiety, depression, and high blood pressure. Review of Resident R53's witness statement dated 10/24/24, indicated the resident had to go to the bathroom in the middle of the night. I sat on the toilet and saw diarrhea in my brief. It was indicated she pulled the call bell, and Nurse Aide Employee E6, came and when she asked for assistance with changing her brief, NA, Employee E6…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for incident or accidents for one of six residents (Resident R70). Findings include: The facility Accident and Incident-Investigating and Reporting policy dated 7/1/24, indicated all accidents or incidents occurring on the premises must be investigated and reported to the administrator. Review of clinical record indicated Resident R70 was admitted [DATE], with diagnoses which included chronic atrial fibrillation (heart condition that causes the upper chambers of the heart to beat irregularly and often very fast), bipolar disorder and major depressive disorder. A review of Resident R70's Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 8/7/24, indicated diagnoses remained current. Review of Resident R70 nurse progress notes dated 10/3/24 at 1:16 p.m. Resident R70 was found by the elevator in the basement by a nurse aide around…

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 resident records, admission documentation and staff interview, it was determined that the facility failed to maintain admission documentation for two of three residents (Resident R11, R67). Findings include: Review of Resident R11 was admitted [DATE] with diagnoses that include parkinsonism (neurodegenerative diseases that cause similar motor symptoms, such as rigidity, tremors, and slow movement), adjustment disorder with depressed mood and convulsions. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R11 admission MDS assessment (Minimum Data Set assessment MDS- a periodic assessment of resident care needs) dated 6/18/24 indicated the resident was assessed as having a BIMS score of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exited to an unsupervised and unauthorized location without staff's knowledge) for one of six residents(Resident R70). Findings include: The facility Resident Elopement policy dated 7/1/24, indicated the facility to provide a safe and secure environment for the residents and to be proactive in preventing resident elopement. Review of clinical record indicated Resident R70 was admitted [DATE], with diagnoses which included chronic atrial fibrillation, bipolar disorder and major depressive disorder. A review of Resident R70's Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 8/7/24, indicated diagnoses remained current. Review of Resident R70 nurse progress notes dated 10/3/24 at 1:16 p.m. Resident R70 was found by the elevator in the basement by a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care related to oxygen equipment and management for three of four residents (Residents R33, R44 and R87). Findings include: Review of the facility policy Oxygen Administration dated 7/1/24, indicated oxygen therapy will be ordered as appropriate using nasal cannula (thin flexible tube that goes around the head and into the nose). Change pre-filled humidification systems at least weekly, along with oxygen tubing. Review of the admission record indicated Resident R33 admitted to the facility on [DATE]. Review of Resident R33's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/2/24, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), and depression. Review of Resident R33's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and staff interview it was determined that the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to provide care for a resident requiring subcutaneous injections (insertion of medication beneath the skin) which led to an emergency room visit for one of seven residents (Resident 48). Findings include: Review of the facility's current Licensed Practical Nurse (LPN) Job Description indicated Drug Administration Function: Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of residents. Safety and Sanitation: Ensure that all personnel performing tasks that involve potential exposure to blood or body fluids participate in appropriate in-service training programs prior to performing such tasks. Equipment and Supply Functions: Participate in the development and implementation of the procedure for the safe operation of all nursing service equipment. Review of the admission…

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

Based on clinical record review and staff interviews it was determined the facility failed to report abnormal lab results to the ordering physician timely for one of three residents reviewed. (Resident R58) Findings Include: Review of the facility Notification of Condition Change: Physician policy dated 7/1/24, revealed a change in a resident's condition will be reported to the physician in a timely manner, including abnormal lab values. Review of Resident 58's Physician orders revealed an order dated 11/3/24, for a urine culture (test of urine to determine if there is a Urinary Tract Infection). Review of Resident 58's Laboratory report for the urinalysis revealed the report was final and was reported on 11/4/24. The results had abnormal lab values. Interview with Infection Preventionist, Employee E8 on 11/6/24, at 9:50 a.m. indicated lab results are signed off after it is reviewed by a physician. It was indicated notification to the physician, lab results, and any new orders are documented in the resident's clinical record. Review of Resident R58's clinical record on 11/6/24, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observations, and staff interviews it was determined that the facility failed to provide adaptive feeding devices for one of four residents (Resident R11). Findings include: Review of the facility policy Adaptive Eating Devices dated 7/1/24, indicated adaptive eating devices are pieces of equipment used by patients to enable them to achieve or maintain their highest level of eating independence. It was indicated the director of dining ensures that the patient meal identification states in the alert field the specific adaptive device needed or another system is in place. Review of the admission record indicated Resident R11 admitted to the facility on [DATE]. Review Resident R11's active physician order dated 6/11/24, indicated the resident is to have weighted utensils and divided plate. Review of Resident R11's MDS dated [DATE], indicated the diagnoses of high blood pressure, Parkinson's Disorder (a movement disorder of the nervous system that worsens over time), and dysphagia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to follow physician orders and notify a physician or abnormal glucose readings via a Capillary Blood Glucose (CBG) level as ordered for one of four residents (Resident R1). Findings include: Review of facility Hypoglycemia Protocol indicated if a resident has asymptomatic (without symptoms) low blood glucose (less than 70 or physician ordered parameter), treatment includes hold all diabetic medications, including insulin and oral medications. Administer rapidly absorbed simple carbohydrate such as 4 ounces juice, or 5 or 6 ounce regular soda pop or tube of glucose gel per resident's routine. Repeat blood glucose measurement in 10-15 minutes. Notify physician per ordered parameters. Document physician notification and response. The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most…

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 a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that weights were monitored as ordered for one of four residents (Resident R1). Findings include: Review of facility policy Weight Monitoring and Weight Loss Intervention dated 7/1/23, indicated all residents will be weighed on admission, readmission, and at least monthly. More frequent weights may be obtained per facility policy. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (a periodic assessment of care needs) dated 3/28/24, indicated diagnoses of renal failure (failure of the kidneys resulting in an inability to filter blood and remove waste), diabetes (too much sugar in the blood), and hemiplegia (paralysis on one side of the body). Review of a physician order dated 3/27/24, indicated to obtain weekly weights every Wednesday for four weeks. Review of Resident R1's Medication…

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, clinical record review, job description review, observation, and staff interview, it was determined the facility failed to provide care and services to meet the accepted standards of practice for four of five residents (Resident R36, R41, R76, and R84). Findings: Review of the facility's Medication Administration policy dated, 7/1/23, indicated medications are administered, as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so to comply with federal Laws governing Medication Administration and in order to ensure the safe, accurate, and timely administration of medications. It was indicated medications must be administered within 60 minutes before or after the scheduled times. It is stated unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility. Review of Resident R36's Minimum Data Set (MDS-periodic review of care…

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, resident council group interview, resident and staff interview it was determined that the facility failed to uphold resident rights and offer residents the opportunity to vote for the November 2023 election for one of three sampled residents (Resident R6). Findings include: The facility Resident voting policy dated 8/2016, last reviewed 7/1/23, indicated that staff will assist all residents to exercise his or her rights as a citizen. This includes, the right to vote. During a resident council group interview on 12/19/23, at 1:30 p.m. ten out of 11 residents stated they did not receive assistance with registering to vote for the November 2023 election. During an interview on 12/20/23, at 9:14 a.m. the Activities Director Employee E7 stated: I ask the residents if they want to vote. Most of the residents are registered to vote with a mail in ballot. During an interview on 12/20/23, at 10:56 a.m. the Activities Director Employee E7 stated: I looked through my desk. I was only able to find documentation showing proof for two residents. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, closed clinical records, resident fund account statements and staff interview it was determined that the facility failed to convey resident funds in accordance with State law and closed accounts upon death in a timely manner for one out of five closed resident records (Closed Resident Records CR246). Findings include: The facility Resident fund distribution policy dated 9/2017, and last reviewed 7/1/23, indicated that available funds in the account will be distributed for burial arrangement, returned to the legally responsible party or submitted to the Estate Recovery fund if applicable within 30 days of death. Review of Closed Resident Records CR246's admission record indicated she was admitted on [DATE], with diagnoses that included hypertension (a condition impacting blood circulation through the heart related to poor pressure), fracture of one rib, schizoaffective disorder (a mental condition characterized by delusions, hallucinations, or disorganized thought impacting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician of abnormal blood pressure for two of two residents (Resident R14 and R84). Findings include: The facility Protocol-When to Call the Doctor policy dated 7/1/23, indicated the physicians caring for residents in the facility want to respond in an appropriate and timely manner to changes in condition as determined by nursing staff to address any concerns voiced by staff, residents, or family members. It was indicated the physician must be notified if a resident has vital signs abnormalities. The Centers for Disease Control defines blood pressure as the pressure of blood pushing against the walls of your arteries. Arteries carry blood from your heart to other parts of your body. High blood pressure, also known as hypertension, is blood pressure that is higher than normal. The higher your blood pressure levels, the more risk you have for other health problems, such as heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, documents and clinical record and staff interview, it was determined that the facility failed to protect residents from neglect for one of four residents reviewed (Resident R79). Findings include: Review of policy titled Abuse: protection from abuse, last reviewed 7/1/23, indicated the resident has the right to be free from sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. Review of admission record indicated that Resident R79 was admitted to the facility on [DATE]. Review of Resident R79's Minimum Data set (MDS- a periodic assessment of care needs dated 1/13/23, indicated diagnosis chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs) , diabetes mellitus, dementia (loss of thinking, remembering, and reasoning skills) and anxiety disorder. Review of facility submitted documentation dated 2/28/23, revealed that Resident R79 soaked in urine 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, resident and staff interviews it was determined that the facility failed to provide discharge planning for resident needs prior to discharge for one of four residents (Resident R94). Findings include: Review of the facility's Post Discharge Plan policy dated 7/1/23, indicated when a facility anticipates a residents discharge to a private residence, a post discharge plan will be developed which will assist the resident to adjust to his or her new living environment. The resident or representative should provide the facility with a minimum of a 72 hour notice of a discharge to assure that an adequate discharge plan can be developed. Failure to comply with this rule could result in the facility being unable to develop a discharge plan and the medical record must be documented as to the reason why a discharge plan was not developed. Review of Resident R94's clinical record indicated the resident was admitted to the facility on [DATE], with the following…

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 a review of facility policy, clinical record review, resident interview, resident council group interview and staff interview, it was determined that the facility failed to provide care and services regarding bathing for one of four sampled residents (Resident R42). Findings include: The facility Flow of care policy last reviewed 7/1/23, indicated that care will be provided to residents 24-hours a day to attain and maintain the highest level of functioning. Residents are to have two baths or showers a week unless the resident states otherwise. Review of Resident R42's admission record indicated he was originally admitted on [DATE], with diagnoses that included bipolar disorder (a mental condition characterized by alternating periods of elation and depression), paraplegia, neuro-dysfunction of the bladder, history of falling and hypertension (a condition impacting blood circulation through the heart related to poor pressure). Review of Resident R42's MDS assessment (Minimum Data Set--MDS assessment: a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop an individualized care plan to address the resident's specific nutritional concerns and preferences for one of four (Resident R67) records reviewed. Findings include: Review of facility policy MDS/RAI/Care Planning, dated 7/1/23, indicated that residents will have a comprehensive assessment completed by day 14 of stay and a comprehensive care plan completed and reviewed within 7 days of the completion date of the MDS (Minimum Data Set assessment - a mandated assessment of a resident's abilities and care needs). The resident will then be assessed at least quarterly and care plan reviewed by the interdisciplinary team according to OBRA scheduled and more often if required for Medicare reimbursement. Policy further indicated that the facility will develop a written plan of care individualized for each resident, which identifies through an assessment process his/her strengths,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical record, observation and staff interviews it was determined that the facility failed to administer medications with a medication error rate that was less than five percent for two of five residents (Resident R36 and R84). Findings include: Review of the facility's Medication Administration policy dated, 7/1/23, indicated medications are administered, as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so to comply with federal Laws governing Medication Administration and in order to ensure the safe, accurate, and timely administration of medications. It was indicated medications must be administered within 60 minutes before or after the scheduled times. It was indicated unless otherwise specified by the physician, routine medication are adminstered according to the established medication administration schedule for the facility. Five medication errors occurred during 30 observed opportunities, which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical record, observation and staff interviews it was determined that the facility failed it was determined that the facility failed to make certain that residents are free from significant medication errors for one of five residents (Resident R84). Findings include: Review of the facility's Medication Administration policy dated, 7/1/23, indicated medications are administered, as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so to comply with federal Laws governing Medication Administration and in order to ensure the safe, accurate, and timely administration of medications. It was indicated medications must be administered within 60 minutes before or after the scheduled times. Review of Resident R84's Minimum Data Set (MDS-periodic review of care needs) dated 8/4/23, indicated the resident was admitted on [DATE], with diagnoses of high blood pressure, diabetes (a disease that occurs when your blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents and resident clinical record and staff and resident interviews it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement for two of three residents (Resident R11 and Resident R57). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of admission record indicated Resident R11 was admitted to the facility on [DATE]. Review of Resident R11's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/18/20, indicated the diagnoses of down syndrome (a genetic disorder associated with physical growth delays, characteristic facial features and mild to moderate developmental 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 review of facility policy, observations and staff interview, it was determined that the facility failed to maintain call bell equipment for two of five sampled residents (Resident R8 and R51). Findings include: The facility Call lights policy dated 7/1/23, indicated that a call light system is used by the faciltiy to respond to the resident's request. During observations on 12/19/23, at 11:24 a.m. Resident R8 call bell was observed on at first floor nurse station call bell monitor. The monitor showed Resident R8's call bell on for four minutes. Observations of light above Resident R8's room found not functioning. During an interview on 12/19/23, at 11:25 a.m. Housekeeper, Employee E4 confirmed the light above the Resident R8's room was not working. During observations on 12/19/23, at 10:29 a.m. Resident R51 call bell was observed on at third floor nurse station call bell monitor. The monitor showed Resident R51's call bell on for eight minutes. Observations of light above Resident R51's room found not functioning. During an interview on 12/19/23, at 10:30 a.m. Environmental…

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 facility assessment, Nurse Aide (NA) and nurse training documentation and staff interview, it was determined that the facility failed to ensure that nursing staff have annual in-service education necessary to care for residents' needs for four out of six employee records (NA Employee E1, NA Employee E2, NA Employee E13, and Licensed Practical Nurse (LPN) Employee E14). Findings include: The facility assessment dated [DATE], indicated that the facility will maintain adequate trained and competent staff. Mandatory education for employees is delivered and tracked. Topics covered include abuse/neglect, resident rights, dementia overview, disaster preparedness, fire safety, infection control, workplace violence, and restorative nursing. Review of NA Employee E1's employee personnel record indicated he was hired as a nurse aide on 5/20/02 Review of NA Employee E2's employee personnel record indicated she was hired as a nurse aide on 3/29/17. Review of NA Employee E13`'s employee personnel record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to determine the ability to safely self-administer medications for one of six residents reviewed (Resident R294). Findings include: Review of the facility's policy Self-Administration of Medication last reviewed 7/21/22, indicated that the physician must order and the interdisciplinary team must assess the resident's ability to safely self-administer medications. Clinical record review revealed Resident R294 was admitted to the facility on [DATE], with the diagnoses of Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Convulsions (seizures), and Gastric Reflux Disease (stomach acid). Review of Physician Orders dated 12/11/22, indicated the facility failed to obtain an order for Resident R294 to self-administer medications. Review of Resident R294's care plan dated 12/9/22, failed to include a goal or interventions 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, resident interview, and staff interview it was determined the facility failed to make certain the physician orders regarding a resident's wishes regarding life sustaining treatments and the POLST (Physician Order for Life Sustaining Treatment) form were accurate for one of four residents (Resident R38). Findings include: Review of facility policy titled Advanced Care Planning & POLST Process last reviewed 7/ 21/22, indicated requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advanced directive and/or POLST (Physician Orders for Life Sustaining Treatment - a physician order that documents and directs the patient's medical considerations regarding life sustaining interventions.) Upon admission the resident will be offered the opportunity to complete a POLST form, the facility will assist the resident and notify 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 review of facility policy, clinical records, and staff interview, it was determined that the facility failed to revise/update care plans for two of four residents to accurately reflect the current status of the residents (Residents R77 and R294). Findings include: Review of the facility policy Participation in Planning Care and Treatment dated 7/1/21, indicated that the care plan shall be reviewed, evaluated, and updated, as necessary. Review of admission record indicated Resident R294 was admitted to the facility on [DATE], with the diagnoses of Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Convulsions (seizures), and Gastric Reflux Disease (stomach acid). Observation of Resident R294's nebulizer equipment on 12/11/22, at 9:14 a.m. revealed no label indicating date last changed. Review of Resident R294's care plan indicated no goals or interventions for caring for the nebulizer equipment and tubing changes. Review of admission…

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

Based on review of facility documentation and staff interview, it was determine that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program. The findings include: Review of the Activity Director personnel file Employee E17, did not include information regarding the Activity Director having completed a state approved program to be qualified to oversee the Activity Program. During an interview on 12/13/22, at 2:30 p.m., Regional Nurse Employee E16 confirmed that the Activity Director was not qualified to oversee the Activity Program. 28 Pa. Code: 201.18(b)(3) Management.

Based on observation, clinical record review, staff interview, and facility policy it was determined that the facility failed to notify a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as per physician's order for one out of five residents (Resident R63). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, staff and resident interviews, it was determined the facility failed to provide adequate supervision with smoking materials and keep the resident environment free of accident hazards for two of four residents (Resident R40 and R44) and failed to provide an environment free of potential accidents and hazards relating to an electric heater for one of four residents (Resident R74). Findings include: Review of facility policy titled Smoking Policy last reviewed 7/21/22, indicated [Cheswick Rehabilitation and Wellness Center] is a smoke free facility. Designated smoking areas have been established outside the building for those residents, staff or visitors who chose to smoke. Smoking restrictions apply to all smoking methods including cigarettes, pipes, cigars, and electronic cigarettes. Upon admission, residents will be questioned about about the use of electronic cigarettes and informed that these devices are prohibited on the facility premises. To ensure the safety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, weight documentation, and staff interview it was determined that the facility failed to obtain weight monitoring documentation for one of two sampled residents (Resident R54). Findings include: The facility Nutrition Management policy last reviewed on 7/21/22, indicated that the facility will endure that a resident maintains acceptable parameters of nutritional status, such as body weight. Weight loss is a guide in determining nutritional status, an analysis of weight loss should be examined in light of the current diagnoses. If there is a five percent difference in weight, the resident will be reweighed within 72 hours. Review of Resident R54's admission record indicated that he was admitted on [DATE], with diagnoses that included history of lumbar fracture, hypertension (a condition impacting blood circulation through the heart related to poor pressure) anxiety disorder, and hyperlipidemia (elevated lipid levels within the blood). Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, resident records and staff interview it was determined that the facility failed to discontinue the use of a enteral feed for one out two sampled residents (Resident R53). Findings include: The facility Feeding tubes policy reviewed on 7/1/21, indicated that residents that have been identified as requiring nutritional support will receive enteral (Tube) feeding per professional standards. Decisions to discontinue the use of a feeding tube are collaborative and involve the physician, interdisciplinary team, and include the relevance of a feeding tube. Review of Resident R53's admission record indicated she was originally admitted on [DATE], with diagnoses that included dysphagia (difficulty swallowing), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and depressive disorder Review of Resident R53's care plan dated 5/24/22, indicated that the tube feed was required to maintain nutrition status. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for two of two residents reviewed (Resident 294 and R77 ). Findings include: Review of facility policy Oxygen Administration dated 7/21/22, indicated the cannula or mask and tubing will be replaced weekly by nursing staff. Review of admission record indicated Resident R294 was admitted to the facility on [DATE], with the diagnoses of Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Convulsions (seizures), and Gastric Reflux Disease (stomach acid). Observation of Resident R294's nebulizer equipment (nebulizer changes a medication into a mist so it can be inhaled into the lungs) on 12/11/22, at 9:14 a.m. indicated no label indicating date last changed. Review of admission record indicated Resident R77 was admitted to the facility on [DATE]. Review Resident R77's Minimum Data Set…

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 policies, clinical record review and staff interview, it was determined that the facility failed to make certain the highest practicable pain management was achieved for one of four residents (Resident R50). Findings include: Review of facility policy Pain Management Guidelines dated 7/21/22, indicated functions of appropriate pain management include intervening to treat pain before the pain becomes severe and anticipating pain during activities that may be uncomfortable (i.e. dressing changes) and pre-treating with pain medication. Review of admission Record indicated Resident R50 was admitted to the facility on [DATE]. Review of Resident R50's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/1/22 indicated the diagnoses high blood pressure, depression, and falls. Review of Resident R50's care plan dated 11/4/22 indicated to assess for pain before, during and after treatments. Observation of Resident R50's dressing change to right unstageable heel ulcer on 12/12/22, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon clinical record review, and staff interview, it was determined that the facility failed to ensure that any irregularities submitted in the medication regiment reviews (MRR) by pharmacy were acted upon for one out of five sampled residents (Resident R41). Findings include: The facility Unnecessary medications policy last reviewed on 7/21/22, indicated that each resident's drug regimen will be free from unnecessary drugs. There will be evidence that supports a justification of drug use and is in the best interest of the resident, such as a physician's note, a psychiatric consultation or evaluation, documentation confirming previous attempts at dosage reduction, and documentation showing resident's improvement. When antipsychotic drugs are used outside these guidelines without valid reasons, they may be deemed unnecessary drugs. An unnecessary drug is any drug used when in excessive dose, duration, and without adequate indications for use. The facility requires reason and substantiated rationale for use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and interview with staff, it was determined that the facility failed to make certain that PRN (as needed) orders for psychotropic medications are limited to 14 days for one out of five sampled residents (Resident R41). Findings include: The facility Antipsychotic drug policy last reviewed on 7/21/22, indicated that there will be a 14 day limit on PRN orders. Orders may not extend beyond the 14 day limit. A new order for the PRN antipsychotic may be written every 14 days if the physician assesses the resident and documents clinical rationale for the new order. The facility Unnecessary medications policy last reviewed on 7/21/22, indicated that each resident's drug regimen will be free from unnecessary drugs. There will be evidence that supports a justification of drug use and is in the best interest of the resident, such as a physician's note, a psychiatric consultation or evaluation, documentation confirming previous attempts at dosage reduction, 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 review of facility policies, observations, and staff interviews, it was determined that the facility failed to date multi-dose over the counter (OTC) medication bottles in two of five medication carts (1st floor, and 2 [NAME] Cart), and failed to properly secure a medication cart in one of five treatment carts (first floor). Findings include: The facility policy Storage of Medication last reviewed 7/21/22, indicated medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies, and compartments containing medications are locked when not in use and are not left unattended. During an observation on 12/11/22, at 9:14 a.m. of the 1st floor medication cart revealed the following OTC medications were observed open without a date of opening: One bottle - Miralax (stool softener) One bottle - Milk of Magnesium (laxative) One bottle - Geri-Tussin (cough relief) During an interview on 12/11/22, at 9:15 a.m. Licensed Practical Nurse Employee E11 confirmed the facility failed to date OTC medications once opened.…

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 facility assessment, facility in-service training and staff interview it was determined that the facility failed to update the facility assessment to include competencies, resources, and required care for residents with substance abuse concerns for six out of six residents (Residents R13, R17, R18, R40, R64, and Resident R80). Findings include: The facility assessment dated [DATE], indicated that the facility will maintain adequate trained and competent staff. Mandatory education for employees is delivered and tracked. Review of Resident R13's admission record indicated she was admitted on [DATE], with diagnoses that included diabetes ( metabolic disorder impacting organ function related to glucose levels in the human body), opioid abuse (a disorder characterized by misusing opioids, causing difficulty with decreasing use, impacting everyday tasks and creating negative social and physical consequences), and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to prevent the potential for cross contamination during one of three resident dressing changes (Resident R50). Findings include: A review of facility policy Infection Control Program Overview updated 7/21/22, indicated the facility will implement and maintain an infection prevention and control program in order to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. Review of admission record indicates Resident R50 was admitted to the facility on [DATE]. Review of Resident R50's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/1/22, indicated diagnoses of falls, depression and high blood pressure. Review of physician orders for Resident R50 indicated the nurse is to clean the wound to right heel with Normal Sterile Saline (NSS), pat dry, apply Santyl (a collagen wound ointment) to wound base, cover…

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.