Quality Life Services - Chicora

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for three of three residents (Residents R1, R63, and R92).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 11/10/25, indicated diagnoses of high blood pressure, muscle weakness, and need for assistance with personal care. During an observation on 12/1/25, at 9:58 a.m. bilateral (both sides) side rails were observed on the top of Resident R1's bed. Review of Resident R1's comprehensive care plan failed to include measurable objectives and timetables with specific interventions/services for use of bed rails. Review of the clinical record indicated…

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

Based on review of personnel records and staff interview, it was determined that the facility failed to complete annual performance evaluation at least once every 12 months for four of four nurse aide (NA) personnel records (NA Employees E12, E13, E14, and E15). Findings include:Review of NA Employee E12's personnel record indicated a hire date of 7/6/10. Review of NA Employee E12's personnel record failed to include an annual performance evaluation at least once every 12 months as required.Review of NA Employee E13's personnel record indicated a hire date of 2/3/12. Review of NA Employee E13's personnel record failed to include an annual performance evaluation at least once every 12 months as required.Review of NA Employee E14's personnel record indicated a hire date of 3/6/25. Review of NA Employee E14's personnel record failed to include an annual performance evaluation at least once every 12 months as required.Review of NA Employee E15's personnel record indicated a hire date of 1/6/23. Review of NA Employee E15's personnel record failed to include an annual performance…

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

Based on review of the 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 required members for three of three quarters (Quarter one, two, three of 2025).Findings: Review of Quality Assessment and Assurance minutes sign in sheets and attendance records for Quarter One, Two and Three of 2025, failed to reveal the Infection Preventionist was in attendance. During an interview 12/4/25, at 1:30 p.m. Clinical Services Specialist Employee E5 confirmed that the facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly with all the required committee members for three of three quarterly meetings (Quarter one, two, three of 2025), as required. 28 Pa. Code 201.18 (e)(1)(2)(3)(4) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R5), failed to ensure that contact precautions were ordered for two of five residents (Residents R36 and R82) and failed to ensure that contact precautions were care planned for one of five residents (Resident R82) Findings include: Review of facility policy Wound Dressing Change dated 10/13/25, indicated all wound care will be performed using medical aseptic (free from contamination) technique, unless otherwise ordered by physician. The purpose is to prevent contamination of the wound bed. Each area must be treated separately. Review of the facility policy Pediculosis (Lice) Care dated 10/13/25, indicated pediculosis is an infestation of the scalp, the hairy parts of the body, or clothing with adult lice, larvae, or nits. It is transmitted by direct contact with an infested person and indirectly…

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, review of clinical records, observations and staff interview, it was determined that the facility failed to determine whether it was safe to self-administer medications for one of six residents (Resident R25). Findings include: Review of the facility policy Self-Administration of Medications dated 10/13/25, indicated in order to maintain the residents' high level of independence, resident's who desire to self-administer medications are permitted to do so if the facility 's interdisciplinary team has determined the practice would be safe for the resident and other resident's of the facility and there is a prescriber's order to self-administer. Review of the admission record indicated Resident R25 was admitted to the facility on [DATE]. Review of Resident R25's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/17/25, indicated the diagnoses of malignant neoplasm of upper lobe, right bronchus or lung, respiratory failure and chronic kidney disease. Observation…

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, clinical records, facility documents, and staff interviews it was determined that the facility failed to identify a scoop mattress (a specialty medical mattress with soft raised foam edges) as a possible restraint, and failed to assess the functional status of the individual resident to determine if the use of a scoop mattress is a restraint for one of three residents (Resident R63).Findings include: Review of facility policy Physical Restraint Policy and Procedure dated 10/13/25, indicated physical restraints are defined as any manual method of physical or mechanical device, material or equipment attached or adjacent to the elder's body that the individual cannot remove easily which restrict freedom of movement or normal access to one's body. Review of the clinical record indicated Resident R63 was admitted to the facility on [DATE].Review of Resident R63's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/12/25, indicated diagnoses of anemia (too little…

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, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for one of five residents (Resident R92).Findings include: Review of facility policy Care Plan and Interdisciplinary Care Conferences dated 10/13/25, indicated the care plan is a working tool that is reviewed and revised at specific intervals and as needed to reflect response to care and changing needs and goals. Review of the clinical record indicated Resident R92 was admitted to the facility on [DATE]. Review of Resident R92's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/23/25, indicated diagnoses of high blood pressure, diabetes mellitus (DM, a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and End-Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood). Review of a physician order dated 5/6/25, indicated to apply Dexcom G7 Sensor (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 resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis (a machine that filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for two of two residents (Residents R13 and R92).Findings include: Review of the clinical record indicated Resident R92 was admitted to the facility on [DATE]. Review of Resident R92's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes mellitus (DM, a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and End-Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood).Review of a physician order dated 11/5/25, indicated Resident R92 receives dialysis treatment at an outside facility every Monday, Wednesday, and Friday. Review of Resident R92s clinical record did not include complete communication forms for…

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

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medications in one of three medication rooms (Memory Lane Medication Room).Findings include:Review of facility policy Storage of Medications dated 10/13/25, indicated certain medications such as multiple dose injectable vials require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. During an observation on 12/4/25, at 9:14 a.m. of the Memory Lane Medication Room Refrigerator revealed two tuberculin multiple dose vial (a substance used in the tuberculin skin test (TST) to diagnose tuberculosis infection) that was opened and not labeled with the date opened as required.During an interview on 12/4/25, at 9:14 a.m. Licensed Practical Nurse (LPN) Employee E16 confirmed the above observation and that the facility failed to properly store medication in one of three medication rooms (Memory Lane Medication Room).28 Pa. Code: 201(a) Responsibility of licensee.28 Pa. Code: 211.9(a)(1)(k) Pharmacy…

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 provided documents and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections during the periods of 10/4/25, through 10/13/25, and 11/16/25, to present.Findings included:During an interview on 12/5/25, at 1:25 p.m. the Director of Nursing (DON) stated, I was the Infection Preventionist and Assistant Director of Nursing for the period of 10/13/25, - 11/16/25, when I became the Interim DON. Prior to my tenure IP Employee E16's last day of work was on 10/4/25.During an interview on 12/5/25, at 12:30 p.m. the DON confirmed that the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections during the periods of 10/4/25, through 10/13/25, and 11/16/25, to present.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 201.19(3) Personnel records.28 Pa. Code:…

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 staff interview, it was determined that the facility failed to follow resident consent for pneumococcal vaccination and failed to administer the vaccination in a timely manner for one of five residents (Resident R65).Findings include:Review of facility policy Standing Orders for Administering Pneumococcal Vaccine to Adults dated 10/13/25, indicated staff will identify adults in need of vaccination with pneumococcal polysaccharide vaccine (PPSV - a vaccine that protects against 23 types of streptococcus pneumoniae bacteria). Record the date the vaccine was administered, the manufacturer and lot number, the vaccine site and route, and the name and title of the person administering the vaccine. If the vaccine was not given, record the reason for non-receipt of the vaccine.Review of the admission record indicated that Resident R65 was admitted to the facility on [DATE]. Review of R65's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/6/25,…

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.

Based on review of facility education documents, and staff interview, it was determined that the facility failed to provide training on effective communication for one of five staff members (Nurse Aide (NA) Employee E15).Findings include:Review of NA Employee E15's personnel record indicated a hire date of 1/6/23. Review of NA Employee E15's education documents on 12/3/25, at 12:00 p.m. failed to include evidence of required communication training.Interview on 12/3/25, at 2:30 p.m. the Clinical Services Specialist Employee E5 confirmed that the facility failed to provide training on effective communication for one of five staff members (NA Employee E15).28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(6)(d) Staff development.

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 and implement the facilities abuse and neglect policy, and failed to report alleged criminal activity of a Licensed Practical Nurse (LPN) Employee E1 to the proper authorities, which created an immediate jeopardy situation for all 95 of 95 residents.Findings include: The job description for the Nursing Home Administrator dated 4/14/24, indicated the NHA is to direct the day-to-day operations of the facility in accordance with current federal, state, and local standards governing long-term care facilities and to ensure that the highest degree of resident care and services are delivered and maintained. The position is responsible for establishing and maintaining systems that are effective and efficient. Oversee all departments and department supervisors to ensure the Nursing Home is operating safely and efficiently. Operate the company in accordance with the established policies 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 job description, facility documents and staff interviews, it was determined that the facility failed to conduct the minimum 12 hours of nurse aide (NA) training per year for four of four direct care facility staff reviewed (NA Employee E5, E8, E9, and E10). Findings include: Review of the facility Nursing Assistant Job Description indicated the purpose of your job role is to provide direct care to residents, under the supervision of a licensed nurse, in accordance with policies and procedures and report resident needs and concerns to a licensed nurse. Attend all in-service classes as assigned and complete assignments. During an interview on 11/9/2025, at 10:30 a.m. Chief Nursing Officer Employee E7 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2024 revealed the following concerns: Review of NA Employee E5's facility provided information failed to include the minimum 12-hour NA annual training. Review of NA Employee E8's facility provided information failed to include 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 clinical record review, and staff interviews, it was determined that the facility failed to ensure the physician was appropriately notified of change in condition for one of four residents reviewed (Resident R4).Findings include: Review of the facility policy Resident Change in Condition or Status dated 5/19/25, revealed it is the policy of the facility promptly addressing all resident changes in condition and managing them in compliance with all applicable standards of care. When a resident exhibits a change in condition from their baseline, the licensed nurse assigned to the resident will do the following: provide any necessary physical assessment to determine underlying cause, review any available diagnoses, request assistance from other staff as necessary, and ensure timely notification to charge nurse, physician, and family. Documentation must be provided in the resident record regarding: any assessment of the resident and findings, all applicable interventions, and all communication. All…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure that residents' medication regime was free from unnecessary psychotropic (a mind-altering medication) medication for one of three residents (Resident R8). Findings include: Review of facility Behavior Standard Index policy dated 5/19/25, indicated the purpose is to develop and implement behavioral plans, and medication regimes, in efforts to optimize the functional abilities of residents while monitoring for adverse side effects and improve behaviors. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/4/25, indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), anxiety, and high blood pressure. Review of Resident R8's physician order dated 7/14/25 through 10/14/25, indicated to administer Ativan…

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 record review, and staff interviews, it was determined that the facility failed to follow professional standards of practice when documenting for one of eight residents. (Resident R4).Findings include: Resident R4 was admitted to the facility on [DATE], with diagnoses of anxiety, muscle weakness, and high blood pressure. Review of the clinical record physician order dated 6/3/25, indicated Resident R4 was ordered assist with toileting and hygiene every two hours and as needed. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/4/25, indicated diagnoses of anxiety, muscles weakness, and high blood pressure. Question C0500 BIMS Summary Score revealed Resident R4's score to be 4, severe impairment. Section GG-Functional Abilities-revealed the resident required substantial/maximal assistance with toileting transfers and hygiene. and with sit to stand. Review of Resident R4's late entry progress note effective 10/13/25, entered…

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, and staff interview, it was determined that the facility failed to ensure a resident is provided non-pharmacological interventions and an assessment prior to administering as needed pain medications for one of seven residents (Resident R1).Findings include: Review of facility policy Pain Assessment and Management dated 5/19/25, indicated all residents are screened for the presence of pain evaluated periodically for the presence of pain. Observe residents who are cognitively impaired/comatose or who have difficulty communicating for physical signs of pain including: grimaces, frowning, crying, change in behavior, loss of function, decreased activity level, resistance to care, agitation, eating or sleeping poorly to evaluate. Balance interventions for pain management with an adequate response to provide comfort while maintaining functional status and quality of life. Document screening for presence of pain, assessment of pain, interventions and resident'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 review of clinical records, and staff interviews, it was determined that the facility failed to implement fall prevention interventions and conduct post fall monitoring for one of four residents (Resident R4).Findings include: Review of the facility policy Resident Change in Condition or Status dated 5/19/25, revealed it is the policy of the facility promptly address all resident changes in condition and to manage them in compliance with all applicable standards of care. When a resident exhibits a change in condition from their baseline, the licensed nurse assigned to the resident will do the following: provide any necessary physical assessment to determine underlying cause, review any available diagnoses, request assistance from other staff as necessary, and ensure timely notification to charge nurse, physician, and family. Documentation must be provided in the resident record regarding: any assessment of the resident and findings, all applicable interventions, and all communication. All documentation…

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 interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of four residents reviewed (Resident R6).Findings include: Review of facility policy Medication Administration-General Guidelines reviewed 5/19/25, stated medications are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to do so. Personnel authorized to administer medication do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). Five rights- Right resident, right drug, right route and right time, and applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from…

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

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to one of five direct care facility staff reviewed (Employee E5).Findings include: Review of the facility Nursing Assistant Job Description indicated the purpose of your job role is to provide direct care to residents, under the supervision of a licensed nurse, in accordance with policies and procedures and report resident needs and concerns to a licensed nurse. Attend all in-service classes as assigned and complete assignments. During an interview on 11/9/2025, at 10:30 a.m. Chief Nursing Officer Employee E7 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2024 revealed the following concerns: Review of Nurse Aide (NA) Employee E5's facility provided information did not include training on QAPI. During an interview on 11/9/25, at 10:54 a.m. the Chief Nursing Officer Employee E7 confirmed that the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility documents, clinical record review, and staff interview it was determined that the facility failed to revise a care plan to accurately reflect the current status for one of three residents (Resident R1). Findings include: Review of facility policy Care Plan and Interdisciplinary Care Conferences dated 11/8/24, indicated that the purpose of a care plan is to structure and guide therapeutic interventions to meet resident's needs and achieve expected outcomes. The care plan is formally reviewed and completed within 21 days after admission at the Interdisciplinary Care Plan Conference and communicated to appropriate staff. The care plan may be specifically reviewed and updated as the resident's condition changes- for example, but not limited to: medications are added or discontinued Resident returns from the hospital Change in resident's mood, behavior, activities of daily living Review of the clinical record revealed that Resident R1 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of sexual abuse was completed for one of four residents (Resident R1). Review of the facility policy Resident Protection from Abuse, Neglect, Mistreatment or Exploitation last reviewed 11/8/24, indicated Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Sexual abuse is defined as non-consensual sexual contact of any type with a resident and includes sexual harassment, sexual coercion or sexual assault. Reporting/Response includes but not inclusive to: The Nursing Home Administrator (NHA) or Director of Nursing (DON) must be notified immediately. The NHA or DON will notify the PA department of health within 24 hours of the incident and complete an on-line PB-22. The…

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

Based on review of facility policies, observations, and staff interviews, it was determined the facility failed to properly date and store food products, and failed to maintain clean equipment in a manner to prevent foodborne illness in the Main Kitchen. Findings include: Review of facility policy Food Storage dated 11/8/24, and previously dated 7/22/24, indicated all foods should be covered, labeled, and dated. Food should be dated as it is placed on the shelves. Review of facility policy Cleaning and Sanitation dated 11/8/24, and previously dated 7/22/24, indicated that food service staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. During an observation in the Baker's Refrigerator on 11/12/24, at 9:55 a.m. three packages of whipped topping were not dated. During an observation in the Stand- Up Freezer on 11/12/24, at 10:00 a.m. three lemon meringue pies were not dated. During an observation in the Walk-in Refrigerator on 11/12/24, at 10:05 a.m. an opened package of sliced…

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 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 five of six residents sampled with facility-initiated transfers (Residents R2, R13, R82, R83, and R88). Findings include: Review of facility policy Medical Emergency dated 7/22/24, and last reviewed 11/8/24, indicated if transfer is required complete transfer form and send appropriate documentation with the resident. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/4/24, indicated diagnoses of high blood pressure, Alzheimer ' s disease (a type of brain disorder that causes problems with memory, thinking and behavior), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, 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 four of six resident hospital transfers or therapeutic leave of absence (Resident R2, R69, R82, and R83). Findings Include: Review of the facility policy Notice of Bed Hold Policy at Time of Transfer Due to Hospitalization or Therapeutic Leave indicated that the bed hold policy will be provided to residents at the time of transfer of a resident for hospitalization or therapeutic leave. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/4/24, indicated diagnoses of high blood pressure, Alzheimer ' s disease (a type of brain disorder that causes problems with memory, thinking 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess a resident for safe smoking for one of two residents (Resident R42), and failed to make certain each resident received adequate monitoring of elopement (leaving an area without permission) prevention devices for three out of three residents (Residents R67, R69, and R72), Findings include: Review of the facility policy Smoking dated 11/8/24, and previously dated 7/22/24, indicated that a Smoking Assessment will be completed upon move-in, quarterly, and as needed if there is a decline in the residents Activities of Daily Living. Review of the facility policy Elopement Prevention dated 11/8/24, and previously reviewed 7/22/24, indicated that if a resident's behavior warrants elopement prevention measures, a comprehensive elopement prevention plan will be documented as part of the plan of care. Staff observations will be noted during the resident's stay 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation and staff interview, it was determined that the facility failed to make certain a medication room refrigerator containing narcotics was properly locked and that open medications stored in the medication room refrigerator were labeled with a dated upon opening for one of two medication rooms ([NAME] Crossings Medication Room), failed to store medications and treatments for residents properly to prevent cross contamination for two of four medication carts ([NAME] Crossing Medication Cart and Settlers Cart 6), and failed to label medications upon opening and ensure medication was in pharmacy labeled medication bag for two of four medication carts ([NAME] Crossing Medication Cart and Settlers Cart 6). Review of facility Management of Controlled Drugs dated [DATE] last reviewed [DATE], indicated that all controlled substances are stored under double lock separate from other medication. Review of facility Storage of Medications dated [DATE], last reviewed [DATE],…

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 properly monitor resident's personal refrigerators to ensure that food is properly stored and maintained for two of four residents (Residents R16 and R68), failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R46), failed to review annual infection control policies for ten out of ten years (2014 through 2024), and failed to notify residents or resident representatives of two out of two outbreaks ( COVID and Norovirus (a virus causing nausea, vomiting, and diarrhea)). Review of facility policy Food Brought in from Outside Source dated 7/22/24, last reviewed 11/8/24, indicated the purpose of this policy is to have procedures in place for the safe and sanitary storage, handling and consumption of food including food and fluids purchased through third party vendors and brought in by family members and other…

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, observation, and staff interview it was determined that the facility failed to provide a dignified dining experience by failing to provide assistance with meals timely for two of six residents (Resident R35 and R55). Findings include: Review of the facility Dysphagia Protocol policy dated 11/8/24, indicated residents who have swallowing difficulties will receive evaluation and treatment interventions to promote adequate nutrition and hydration. Review of the facility Resident Rights policy dated 11/8/24, indicated residents shall be treated with dignity and respect. Review of Resident R35's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R35's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 9/2/24, indicated diagnoses of depression, malnutrition (lack of sufficient nutrients in the body), and Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior). Section…

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 notify the physician of a change in condition for one of seven residents (Resident R1). Findings include: Resident R1 was admitted to the facility on [DATE]. Review of the MDS (Minimum Data Set a periodic assessment of resident needs) dated 9/30/24, indicated diagnosis of hyperlipidemia (abnormal levels of fat in the blood), and depression (mood disorder that causes persistent feeling of sadness and loss of interest). Review of Resident R1's clinical record, progress notes dated 9/15/24, indicated, Aide notified writer that resident has scratches on right hip area non open, red raised, white heads on bumps, 3 small, raised patches on abdomen and right front side, yeast infection under left breast bright pink in color non open, odor, right breast small light pink rash starting, writer told aides to clean under breast, dry very well apply anti-fungal cream not powder under breast, apply orange tube barrier cream…

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 admission documents and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) form and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands for one of three residents (Resident R84). 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 the clinical record indicated Resident R84 was admitted to the facility on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation clinical record review and staff interview it was determined that the facility failed to obtain a physician order and develop a resident centered care plan for the placement of a bed against the wall for one of two residents (Resident R42). Review of the facility policy Physical Restraint dated 7/22/24, last reviewed 11/8/24, indicated each resident is to attain and maintain his/her highest practical well-being in an environment that prohibits the use of restraints for discipline or convenience and limits use of restraints use to circumstances in which the resident has medical symptoms that warrant the use of restraint, the use of restraint will be a last resort alternative intervention. Review of the facility Resident Rights dated 7/22/24, last reviewed 11/8/24, indicated a resident shall be free of restraints. Review of Resident R42's clinical record indicated an admission date of 6/7/24. Review of resident 42's MDS dated [DATE], indicated the diagnosis 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 review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure appropriate treatment and services were provided for residents with an indwelling urinary catheter (a tube inserted in the bladder to drain urine) for one of four residents reviewed (Residents R88). Findings include: Review of facility policy Indwelling Urinary Catheter dated 7/22/24, and last reviewed 11/8/24, indicated that an indwelling catheter not medically justifies will be discontinued as soon as clinically warranted. The catheter bag should have a privacy cover applied at all times unless it has one built in by the manufacturer. Review of the clinical record indicated Resident R88 was admitted to the facility on [DATE]. Review of Resident R88's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/28/24, indicated the diagnosis of anemia (low iron in the blood), hypertension (high blood pressure), and neurogenic bladder (a bladder dysfunction caused by…

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 interviews, it was determined that facility staff failed to maintain ongoing communication with the dialysis (a machine filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for two of three residents reviewed (Resident R57, and R59). Findings include: Review of CMS guidelines, 483.25(1) states the facility assures that each resident receives care and services for the provision of dialysis (a machine filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) including the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments. Review of the clinical record indicated that Resident R57 was admitted to the facility on [DATE]. Review of Resident R57's Minimum Data Set (MDS - periodic assessment of care needs) dated 9/6/24, indicated the diagnoses 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 review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R1). Findings include: Review of facility policy Physician Orders dated 7/22/24, and last reviewed 11/8/24, indicated physician orders are followed in accordance with good nursing principles and practices and are transcribed and carried out by persons legally authorized to do so. Medications and treatments will be administered and signed off per physician orders. If dose is missed, take dose as scheduled; do not double dose. Review of Davis's Drug Guide for Nurses, 19th Edition, dated 2024, indicated Mercaptopurine is a medication used to treat Crohn's disease (a long-time disease that causes inflammation and irritation in the digestive tract) by reducing irritation and inflammation in the intestines. Review of the clinical record indicated Resident R1 was admitted to the…

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

Based on review of facility policy, 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 of the required committee members for one of three quarters (January 2024 through March 2024). Findings include: Review of facility policy Quality Assurance Performance Improvement (QAPI) Structure, Scope and Plan dated 7/22/24, and last reviewed 11/8/24, indicated a QAPI Committee shall be established to administer the QAPI Plan as it pertains to that home. Members of the homes' QAPI Committee will consist of at least the following: Nursing Home Administrator, Director of Nursing, Medical Director, Personal Care Administrator, Consultant Pharmacist, Direct Care Team Member, Medical Records representative, Laundry/Housekeeping Director, Maintenance Director, Activities Director, Social Worker, Culinary Director, Human Resources Director, RNAC, at least one member of the Safety Committee, Laboratory representative, Community Member, and Representatives from any…

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 and documents, and staff interview, it was determined that the facility failed to provide training on effective communication for one of five staff members (Nurse Aide (NA) Employee E9). Findings include: Review of the facility's Employee Handbook indicated as required by the Commonwealth of Pennsylvania and in order to maintain the high degree of skill and ability necessary to ensure superior resident care, all employees are required to participate in mandatory or approved meetings, in-service training programs and online courses. Review of NA Employee E9's personnel file indicated a hire date of 3/12/18, and failed to include effective communication training between 11/14/23, and 11/14/24. During an interview on 11/14/24, at 2:00 p.m. the Director of Nursing confirmed that the facility failed to provide training on effective communication for one of five staff members as required. 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 201.20(c) Staff Development.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect by not using the safest transfer status for one of two residents (Resident R2). Findings include: Review of facility policy Resident Protection From Abuse, Neglect, Mistreatment or Exploitation dated 7/22/24, indicated neglect is the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide that to the resident, that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS -…

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, facility policy, clinical records, observation, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of 15 residents (Resident R1), failed to accurately complete assessments and monitor safety device for 15 out of 15 residents, and failed to ensure that residents were transfered safely using the safest transfer status for one of two residents (Resident R2) Findings include: Based on facility policy Elopement Prevention dated 7/22/24, indicated the facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. Upon admission, readmission, quarterly and as necessary, nurses will complete a Wandering Risk Assessment. Should the resident's behavior warrant elopement prevention measures, a comprehensive elopement…

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 and staff interviews it was determined that the facility failed to provide a clean safe homelike environment in one of five shower rooms (Miller's Crossing Nursing Unit Shower room). Findings include: A review of facility Housekeeping Services policy date 2/9/24. indicated that housekeeping service promote a safe and sanitary environment. A review of facility Maintenance Department policy date 2/9/24, indicated that the department conducts on-going monitoring of the facility for areas needing repair. During an observation on 7/19/24, at approximately 10:00 am it was revealed that the shower stall in the Miller's Crossing Nursing Unit shower room contained a brown substance on the back wall, the flooring contained a build up of debris and grime along the baseboard and corners and the facility failed to safely secure the baseboard to prevent possible resident injury. During an interview on 7/19/24, at 10:15 the Nursing Home Administrator confirmed that the shower stall in Miller's Crossing Nursing Unit had a brown substance along…

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, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect by not providing adequate supervision for one of three residents (Resident R1) resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) from the facility. Findings include: Review of facility policy Resident Protection From Abuse, Neglect, Mistreatment or Exploitation dated 2/9/24, indicated neglect is the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide the to the resident, that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to failed to implement written policies and procedures to ensure a complete and thorough investigation of an incident involving the potential for neglect for one of three residents (Resident R1) resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) from the facility. Findings include: Review of facility policy Resident Protection From Abuse, Neglect, Mistreatment or Exploitation dated 2/9/24, indicated neglect is the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide the to the resident, that has resulted in or may result in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) to rule out neglect for one of three residents (Resident R1). Findings include: Review of facility policy Resident Protection From Abuse, Neglect, Mistreatment or Exploitation dated 2/9/24, indicated neglect is the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide the to the resident, that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. All reports of abuse, neglect, exploitation, or mistreatment…

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, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs after a resident eloped (resident exits to an unsupervised or unauthorized area without the facility's knowledge) from the facility for one of three residents (Resident R1). Findings include: Review of facility policy Elopement Prevention dated 2/9/24, indicated the facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. Upon admission, readmission, quarterly and as necessary, nurses will complete a Wandering Risk Assessment. Should the resident's behavior warrant elopement prevention measures, a comprehensive elopement prevention plan will be documented as part of the care plan. Staff observations will be noted during the resident's stay and modifications will be made to the care plan and prevention…

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, facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of three residents (Resident R1). Findings include: Based on facility policy Elopement Prevention dated 2/9/24, indicated the facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. Upon admission, readmission, quarterly and as necessary, nurses will complete a Wandering Risk Assessment. Should the resident's behavior warrant elopement prevention measures, a comprehensive elopement prevention plan will be documented as part of the care plan. Staff observations will be noted during the resident's stay and modifications will be made to the care plan and prevention techniques. Review of facility policy Accidents and Incidents…

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

Based on observations, facility policy and staff interviews it was determined that the facility failed to maintain sanitary conditions in the Main Kitchen and one out of four unit refrigerators (Memory Lane) which created the potential for cross contamination and food-bourne illness. Findings include: During an observation on 1/17/24, at 9:30 a.m. it was revealed one ice machine in the main kitchen contained a brown substance inside the machine. Review of work history report dated September 2023-July 2024, it was revealed the ice machine was last serviced 12/18/23. Review of facility policy Unit Nourishment Centers-CU3.17. Dated 1/6/23, indicated that food service staff will rotate stock and remove outdated items. Check the temperatures of the refrigerators/freezers in the units daily, document temperatures, and actions taken for any inappropriate temperatures. During an observation on 1/18/24 at 10:10 a.m. the Memory Lane refrigerator revealed a jar of relish with open date of 4/15 no year or name fuzzy whitish substance growing on top. The freezer revealed two large plastic…

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

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to maintain a clean, safe, homelike environment for one out of four nursing units (Miller's Crossing). Findings include: The facility Protocol: Value of Appearance policy dated 1/6/23, indicated it is the facility policy to maintain a welcoming, clean, safe, and attractive home-like environment. During a tour of the facility's nursing stations and shower rooms, the following was observed: -At 12:41 p.m. on 1/18/24, during an observation of the nursing station on Miller's Crossing the ceiling tile was observed to be damaged with pieces of the ceiling observed on the floor. -At 12:51 p.m. on 1/18/24, during an observation of the shower room on Miller's Crossing the ceiling was observed to be damaged with a piece of drywall screwed into the ceiling. During an interview on 1/18/24, at 12:52 p.m. Nurse Aide, Employee E1 stated that there was a leak at the Miller's Crossing's nursing station and stated there was a hole in the ceiling in Miller's Crossing shower room that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy and clinical record reviews and interview with staff, it was determined that the facility failed to implement, review, and revise a care plan after a fall for one of six residents (Resident R95). Findings include: A review of the facility policy Care Plan and Interdisciplinary Care Conferences dated 1/6/23, indicated the care plan is a working tool that is reviewed and revised at specific intervals and as needed to reflect response to care and changing needs and goals. It was indicated it's purpose is to structure and guide therapeutic interventions to meet resident's needs and achieve expected. The care plan is reviewed and updated at least quarterly and is based on ongoing assessment and evaluation of resident needs. It may be specifically reviewed and updated as the resident's condition changes. A review of the clinical record indicated Resident R95 was admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), hyperlipidemia (high level 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 review of clinical records and staff interview, it was determined that the facility failed to administer medications as prescribed by the physician for two of two residents (Resident R68 and R71) and failed to complete a Registered Nurse assessment on one of five residents following an injury (Resident R95). Findings include: Review of the facility's policy Accidents and Incidents dated 1/6/23, indicates when a resident incident/accident occurs the resident will be assessed by a Registered Nurse (RN). Review of an undated Registered Nurse (RN) job description titled Registered Nurse Position Responsibilities indicated it is the RN's duty to ensure accurate documentation of all incidents/occurrences during the shift. Assist in assessing physical, mental psychosocial status of all residents. A review of the clinical record indicated Resident R68 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus (metabolic disorder impacting organ function related to glucose…

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 interviews, it was determined that the facility failed to make certain that appropriate treatments and services were provided for the removal of a urinary catheter as required for one of five residents (Resident R51). Findings include: Review of the facility Cather: Use of-NU 10.11 policy dated 1/6/23, indicated in select situations, the use of an indwelling catheter (hollow tube inserted through the urethra or suprapubically into the bladder to drain urine) may be appropriate. This method of continence management will be provided when medically indicated by a physician order. Review of the clinical record indicated that Resident R51 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included muscle weakness, obstructive uropathy (blockage of urinary flow), and anemia (deficiency of healthy red blood cells in blood). A review of Resident R51's Minimum Data Set Assessment (MDS, periodic assessment of resident care needs) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for one of two residents reviewed (Resident R17). Findings include: Review of facility policy Ostomy Care dated 1/6/23, indicated that supplies needed for ostomy (an artificial opening in an organ of the body, created during an operation) care included ostomy appliance, with appropriate size and type, and drainage pouch. Review of the admission record indicated Resident R17 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Residents R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/21/23, indicated the diagnoses of COPD, (chronic obstructive pulmonary disease- a group of progressive lung disorders characterized by increasing breathlessness), high blood pressure and muscle weakness. Section H0100 indicated Resident R17 had an ostomy while a 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, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Residents R58). Findings include: Review of facility policy Oxygen Concentrator dated 1/6/23, indicated that water bottles used for oxygen concentrators should be labeled and dated, and changed weekly. Review of facility policy Oxygen Therapy Via Nasal Cannula, dated 1/6/23, indicated that nasal canula (a lightweight tube placed in the nostrils to deliver oxygen) should be labeled with resident's name and date. Nasal cannula should be replaced every seven days, dated, and store in plastic bag when not in use. Review of the clinical record indicated that Resident R58 was admitted to the facility on [DATE]. Review of Residents R58's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/10/23, indicated the diagnoses of respiratory failure (not enough oxygen in the blood), COPD, (chronic obstructive…

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 policies, information provided by the facility, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that staff report an allegation of abuse per the facility's policy for one of 30 residents reviewed (Resident 28). This deficiency was cited as past non-compliance.Findings include:The facility's policy regarding protection from abuse, undated, indicated that it is the policy of Quality Life Services that each of its owned and operated nursing homes treat all residents with kindness, respect, and in a manner that is at all times free from any form of abuse, neglect, or mistreatment. To protect the residents, each home will implement procedures in the areas of screening, training, prevention, identification, investigation, protection, reporting/response, and corrective action. The following procedure will be implemented by the homes when an incident of resident abuse (including injuries of unknown source), unethical behavior, neglect, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident ' s care plan was updated and revised to reflect the resident ' s specific care needs after a resident refused elopement interventions, for one of two residents (Resident R1). Findings include: Review of facility policy Elopement Prevention last reviewed 1/6/23, indicated that should a resident ' s behavior warrant elopement prevention measures, a comprehensive elopement prevention plan will be documented as part of the care plan. Staff observations will be noted during the resident ' s stay and modifications will be made to the care plan and prevention techniques. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident 1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 8/16/23, indicated diagnoses of Huntington's disease (an inherited condition in which nerve cells…

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, facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement for one of two residents (Resident R1). Findings include: Review of facility policy Elopement Prevention last reviewed 1/6/23, indicated that should a resident ' s behavior warrant elopement prevention measures, a comprehensive elopement prevention plan will be documented as part of the care plan. Staff observations will be noted during the resident ' s stay and modifications will be made to the care plan and prevention techniques. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident 1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 8/16/23, indicated diagnoses of Huntington's disease (an inherited condition in which nerve cells in the brain break down over time resulting in progressive movement,…

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.