Mountain Laurel Healthcare And Rehabilitation Ctr

Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms for six of 50 residents reviewed (Residents 23, 24, 40, 48, 90, 105). Findings include:Observations of Resident 23's room on August 11, 2025 at 2:31 p.m. revealed that the STOP sign on her door used to prevent wandering residents from entering her room, was tattered, torn, and stained.Observations of Resident 24's room on August 11, 2025 at 2:33 p.m. revealed that the STOP sign on her door used to prevent wandering residents from entering her room, was tattered, torn, and stained.Observations of Resident 40's room on August 11, 2025 at 2:34 p.m. revealed that the STOP sign on her door used to prevent wandering residents from entering her room, was tattered, torn, and stained.Observations of Resident 48's room on August 11, 2025 at 2:37 p.m. revealed that the STOP sign on his door used to prevent wandering residents from entering his room, was tattered, torn, and stained.Observations of Resident 90's room on August 11, 2025 at 2:44…

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 interviews, it was determined that the facility failed to ensure that proper care to prevent infection was provided for one of 50 residents reviewed (Resident 23). Findings include:A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated May 19, 2025, indicated that the resident had severe cognitive impairment, required extensive assistance with daily care tasks, and had intermittent urinary catheter procedures. A nursing note for Resident 23, dated February 19, 2025, revealed that the resident's urine sample obtained earlier in the week was not labeled and needed redrawn. Nursing note dated February 21, 2025 revealed that the urine sample could not be flexed and therefore, needed redrawn again. A nursing note dated February 25, 2025 revealed that the urinary results were inconclusive and that the urine sample would need obtained again. Since the resident was symptomatic the physician ordered an antibiotic without having urinary sample test results. 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide showers as scheduled for 5 of 50 residents reviewed (Residents 17, 71,77, 86, 100) and failed to have sufficient staff to have the first floor main dining room open for 5 of 50 residents reviewed (Residents 46, 69, 81, 83, 95). Findings include:An annual Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 17, dated May 5, 2025, revealed that the resident was cognitively intact and required maximum assistance from staff for personal care needs. The current care plan for Resident 1 revealed she is to receive her showers on Tuesdays and Fridays on evening shift.Review of Resident 17's bathing records for May and June 2025 revealed that the resident received one shower in the last 34 days. She did not refuse any showers.An annual MDS assessment for Resident 71, dated, April 7, 2025, revealed that the resident was cognitively intact and required moderate…

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 reviews and staff interviews, it was determined that the facility failed to respond to a pharmacy recommendation for one of 50 residents reviewed (Resident 46) and failed to provide a rationale for not referring the resident to psychiatric care per pharmacist's recommendations (R8).Findings include:An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated August 14, 2025, revealed that the resident was cognitively intact and required moderate assist from staff for daily care needs.Pharmacy medication regimen review reports for Resident 46 dated January 31, 2025, March 26, 2025, April 29, 2025, June 29, 2025, and July 30, 2025 provided to the facility, included recommendations for the physician; however there was no documented evidence that they were addressed by the physician.An interview with the Director of Nursing on August 13, 2025, at 2:22 p.m. confirmed that the above pharmacy consultant reports were not addressed by the physician.An admission MDS assessment for Resident 8, 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.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and serve food in accordance with professional standards for food service safety.Findings include:The facility's dietary policy regarding personal hygiene, dated October 15, 2024, revealed that staff were to cover all hair, including facial hair with a restraint, either with a hairnet, cap, or hat.Observations in the kitchen on August 14, 2025at 8:01 a.m. revealed Dietary Aide 6 at the dishwasher working with the sanitized dishes without a beard restraint.Interview with the Dietary Director on August 14, 2025, at 11:15 a.m. confirmed that Dietary Aide 6 should have been wearing a beard restraint/guard while in the kitchen.The facility's food labeling policy, dated October 15, 2024, revealed that each food item, once opened, was to be securely closed, labeled and dated before being returned to the refrigerator or freezer. Observations in the main kitchen on August 11, 2025, at 9:02 a.m. revealed an opened and undated three-quarter full gallon…

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 a list of nurse aides currently employed by the facility, including their hire dates and training hours, as well as staff interviews, it was determined that the facility failed to ensure that nurse aides had 12 hours of in-service training annually for four of four nurse aides reviewed (Nurse Aide 6, Nurse Aide 7, Nurse Aide 2, and Nurse Aide 8). Findings include:A list of nurse aides provided by the facility revealed that based on their months and dates of hire:Nurse Aide 6 should have received at least 12 hours of in-service training between May 31, 2024, and May 31, 2025. However, there was no documented evidence that she received the 12 hours of training as required.Nurse Aide 7 should have received at least 12 hours of in-service training between December 13, 2023, and December 13, 2024. However, there was no documented evidence that she received the 12 hours of training as required.Nurse Aide 2 should have received at least 12 hours of in-service training between July 10, 2024, and July 10, 2025. However, there was no documented evidence that she received…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about a change in condition for one of 50 residents reviewed (Resident 58).Findings include: The facility's policy regarding changes in condition, dated October 15, 2024, indicated that the nurse would notify the resident's attending physician when there was a change in the resident's medical, mental condition and/or status. A nurse will notify the attending physician when there was refusal of treatment or medications two or more consecutive times.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58, dated May 25, 2025, revealed that the resident was cognitively intact, was understood, could understand, was independent with care needs, used insulin medication (manages blood glucose levels), and had diagnoses that included diabetes mellitus (disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting…

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, as well as staff interviews, it was determined that the facility failed to notify the resident's representative in writing regarding the reason for transfer to the hospital and to ensure that a bed-hold notice was provided to the resident's responsible party for two of 50 residents reviewed (Residents 22 and 46). Findings Include:A nursing note for Resident 22 dated, April 11, 2025, at 3:47 a.m. revealed that the resident was moaning in pain. The facility attempted to contact her son three times without a response, and new orders were given by the medical doctor to send Resident 22 to the emergency room.Review of Resident 22's clinical record revealed no documented evidence that that resident representative was notified in writing of the transfer to the hospital, and there was no documented evidence that a bed hold notice was provided.A nursing note for Resident 46 dated, July 22, 2025, revealed that the resident had a fall and was transferred to the emergency room with complaints of pain in her right shoulder.Review of Resident R46's 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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders for enteral tube feedings (feeding through a tube inserted directly into the stomach) was followed for one of 50 residents reviewed (Resident 7).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated July 20, 2025, indicated that the resident was a quadriplegic (paralysis affecting all four limbs) required enteral feedings due to a decreased appetite and needed assistance from staff for care. Physician's orders for Resident 7, dated January 10, 2025, included an order for the resident to receive Osmolite1.5 (a liquid nutritional product) (may substitute Diabetisource) via feeding tube (enteral nutrition-a way to deliver liquid nutrition through a flexible tube surgically placed in the stomach or digestive system) at a rate of 90 milliliters per hour, with a start time of 8:00 p.m. to run for 11 hours, (for a total of 990 milliliters). A review of Resident 7's…

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

Based on a review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 50 residents reviewed (Resident 58).Findings include:A facility policy regarding diabetes protocol, dated October 15, 2024, indicated that the physician would help individuals with elevated blood sugar and confirmed diabetes and that insulin medication given to a resident shall be prescribed by the physician.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58, dated May 25, 2025, revealed that the resident was cognitively intact, was understood, could understand, was independent with care needs, used insulin medication (manages blood glucose levels), and had diagnoses that included diabetes mellitus (disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal levels of glucose in the blood). The current care plan for Resident 58 indicated that he was insulin…

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 policies, manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to date an opened insulin pen injector for one of 50 residents reviewed (Resident 18). Findings include:The policy for medication storage and labeling, dated October 15, 2024, indicated that when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. Manufacturer's instructions for Tresiba insulin (an ultra long acting insulin that helps control blood sugar for up to 42 hours) indicated that after the first opening it may be kept at room temperature for up to 8 weeks (56 days). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and 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 clinical record reviews and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that drink preferences were honored for 2 of 50 residents reviewed (Residents 71, 101).Findings include: An interview with Resident 71 on August 11, 2025, at 10:13 a.m. revealed that she wanted to have soda as a drink choice, either for meals or for a snack. The resident said that they were told they could purchase their own soda from the vending machines in the building, or they could have someone bring soda in for them, but it would no longer be supplied by the facility. She was informed that she would be provided a ginger ale if she was sick.Interview with Resident 101 on August 13, 2025, at 12:08 p.m. revealed that he would like to have soda as a drink of choice. He is currently having to spend his own money out of pocket, separate from what the facility gets paid each month, for soda because he would like something besides ginger ale if he were sick. He would like different sodas as a choice for either meals or a snack.Interview with…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending September 26, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending August 14, 2025, identified repeated deficiencies related to quality of care; bowel/bladder incontinence, catheter, and urinary tract infection; and food procurement, storage, preparation, service and sanitation.The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending September 26, 2024,…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide medications as ordered by the physician for two of 44 residents reviewed (Residents 55, 84). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 55, dated June 7, 2024, revealed that the resident was cognitively intact, dependent on staff for daily care tasks, and had diagnoses that included hypotension (low blood pressure). Physician's orders for Resident 55, dated September 5, 2024, included an order for the resident to receive 2.5 milligrams (mg) of Midodrine two times per day for hypotension and to hold the medication if the systolic blood pressure (top number) is greater than 130. However, the resident's Medication Administration Record (MAR) for September 2024 revealed that staff were not obtaining or recording the resident's blood pressure prior to administering the medication. Interview with the Director of Nursing on September 26, 2024, at 1:15 p.m. confirmed that staff were not…

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

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide appropriate care to prevent urinary tract infections for one of 44 residents reviewed (Resident 118) who had an indwelling urinary catheter. Findings include: The facility policy for urinary catheter care, dated October 2023, indicated that the resident's care plan was to be reviewed for any special needs of the resident with a urinary catheter. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 118, dated August 18, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care activities, had an indwelling urinary catheter, and had diagnoses that included obstructive uropathy (urine cannot exit the bladder). Physician's orders for Resident 118, dated June 21, 2024, included an order for a 20 French urinary catheter with a 5 cubic centimeter (cc) balloon to straight gravity drainage for urinary retention. A nursing note, 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.

Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for one of 44 residents reviewed (Resident 4). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated August 13, 2024, revealed that the resident was cognitively impaired and had diagnoses which included Post Traumatic Stress Disorder. A care plan for the resident, dated July 3, 2024, revealed that the resident was at risk for behaviors related to his mental illness. A psychological evaluation, dated December 5, 2023, for Resident 4 indicated that the resident suffered from PTSD related to having seen his best friend die in a war, his wife committed suicide, and his father was both physically and mentally abusive…

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 investigation reports, as well as staff interviews, it was determined that the facility failed to provide the necessary services and failed to make certain appropriate treatment and services for dementia were provided to ensure the safety for one of 44 residents reviewed (Resident 109). Findings include: The facility's dementia policy, dated October 2023, revealed that the interdisciplinary team (IDT) will identify and document the resident's condition and level of support needed during care planning and review changes as they arise. Progress or persistent worsening of symptoms and need of increased staff support will be reported to the IDT. The IDT will adjust interventions and the plan depending on the individual's response to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes. The facility's behavior management policy, dated October 2023, revealed that 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 observations, as well as resident and staff interviews, it was determined that the facility failed to have sufficient dietary staff to enable the main dining room to be open for meal times. Findings include: Observations of the main dining room on September 23, 2024, at 12:18 p.m. revealed that there were no residents eating lunch in the dining room. Interview with Resident 8 on September 23, 2024, at 12:32 p.m. revealed that she would like to eat in the dining room for her meals. Interview with Resident 50 on September 23, 2024, at 11:45 a.m. revealed that she would like to go the dining room for the conversation and socialization with others during her meals. Interview with Resident 15 on September 23, 2024, at 11:49 a.m. revealed that she would like to go to the dining room for her meals. Interview with Resident 71 on September 23, 2024, at 11:53 a.m. revealed that she would like to eat in the dining room so that she could get a hot cup of coffee, but that she was told there was not enough staff to open the dining room. Interview with Resident 111 on September 23, 2024,…

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

Based on review of faciliy policy, observations, and staff interviews, it was determined that the facility failed to prepare and store ice under sanitary conditions for one of three ice machines (second floor kitchenette) and failed to maintain a sanitary refrigerator on the first floor kitchenette. Findings include: A facility policy for resident personal food storage, dated October 2023, revealed that all food and beverage must be labeled and dated with the resident's name and date, otherwise it shall be discarded. Observations of the ice machine in the second floor kitchenette revealed that the drain pipe coming from the machine extended down from the machine and into the floor drain grate with a clear tube over the drain pipe directly into the drain grate. There was no air gap between the end of the ice machine's drain pipe and the floor drain. Observations of the refrigerator in the first floor kitchenette on September 25, 2024, at 10:47 a.m. revealed a dark, removable substance in the bottom of the freezer, a full carton of orange sherbet that had expired, nine undated 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 the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending October 5, 2023, and complaint investigation surveys ending December 1, 2023; February 5, 2024; and May 2, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending September 26, 2024, identified repeated deficiencies related to providing an environment free from abuse, the development of comprehensive care plans, revision of comprehensive care plans, providing quality care, providing a safe environment free 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 a review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to protect the residents rights for one of 44 residents reviewed (Resident 47). Findings include: The facility's policy regarding resident rights, dated October 2023, indicated that the resident had the right to retain and use personal possessions including furnishings and clothing, and the right to be informed, in advance, of changes to the resident's plan of care. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 47, dated August 22, 2024, revealed that the resident was cognitively intact, was understood and was able to understand others, was able to make her needs known, was dependent on staff for her care, and was on a therapeutic diet. Observations of Resident 47's room on September 23, 2024, at 1:27 p.m. revealed that the resident did not have any food items brought in from family in her room. Resident 47 had one eight-ounce can of ginger ale that was half…

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, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 44 residents reviewed (Resident 58). Findings include: The facility's policy regarding abuse and neglect, dated October 2023, indicated that the residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Neglect was defined as 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. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58, dated May 2, 2024, revealed that the resident was sometimes understood, could sometimes understand others, and had a diagnosis which included dementia. The resident's care plan, dated September 20, 2023, revealed that the resident was…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the state ombudsman and/or the resident and resident's responsible party in writing regarding the reason for transfers/discharge to the hospital for five of 44 residents reviewed (Residents 30, 44, 48, 56, 118). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 30, dated September 7, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included dementia. Nursing notes for Resident 30, dated July 23, 2024, revealed that the licensed practical nurse was notified by the nurse aide that she heard the resident yelling and when she went back to her room, she saw the resident kneeling on the floor by her bed. The resident tried to adjust herself for comfort, and while doing that they heard two loud pops. The resident stated she had some leg pain. She was aware that her femur (thigh bone) was fractured and that she will be going 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that resident-centered care plans were developed and implemented for three of 44 residents reviewed (Residents 4, 47, 111) regarding Post Traumatic Stress Disorder (PTSD), dialysis, and smoking. Findings include: The facility's current policy for care plans revealed that the comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated August 13, 2024, revealed that the resident was cognitively impaired, dependent on staff for daily care tasks, and had diagnoses that included PTSD. A psychological evaluation for Resident 4, dated December 5, 2023, indicated that the resident was diagnosed with PTSD after witnessing his friend's death in a war, his wife committed suicide, and he…

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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for three of 44 residents reviewed (Residents 44, 90, 109). Findings include: The facility's current policy for care plans indicated that the Interdisciplinary team must review and update the care plan when there has been a change in the resident's condition. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 44, dated August 29, 2024, indicated that the resident was cognitively intact, required supervision from staff for daily care needs, did not have an intravenous access site, and was always continent of urine. The current care plan for Resident 44 revealed that the resident had a potential for complications regarding a Peripherally Inserted Central Catheter (PICC line-a long, thin tube that's inserted through a vein in the arm and passed through to the larger central veins near…

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

Based on review of facility policy, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to ensure a safe environment related to smoking for one of 44 residents reviewed (Resident 46). Findings include: A facility policy for smoking for residents dated, October 2023, revealed that a resident's ability to smoke will be re-evaluated quarterly, upon a significant change (physical or cognitive), and as determined by staff. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated June 27, 2024, indicated that the resident was usually understood, usually understood others, was cognitively impaired, and required supervision from staff for daily care needs. A care plan for Resident 46, dated September 21, 2024, indicated that she would practice safe smoking. The most current evaluation for smoking for Resident 46, dated March 28, 2024, revealed that the resident was an at-risk smoker and required supervision or physical support to smoke. There was no documented…

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 manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent. Findings include: Observations during medication administration on September 25, 2024, revealed that two medication administration errors were made during 25 opportunities for error, resulting in a medication administration error rate of eight percent. Manufacturer's instructions for Fluticasone nasal spray (a medication to treat allergies), dated January 2019, indicated that before using the spray, the user was to blow his/her nose to clear the nostrils, then insert the applicator into a nostril, keeping the bottle upright, close off the other nostril, breathe in through the nose, and while inhaling, press the pump to release the spray. Physician's orders for Resident 60, dated May 9, 2024, included orders for the resident to receive Fluticasone 50 micrograms (mcg), one spray in each nostril daily. Observations during medication administration 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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was offered and/or received the influenza immunizations for one of 44 residents reviewed (Resident 14). Findings include: The facility's policy regarding influenza (flu) vaccines, dated October 2023, revealed that the Infection Preventionist will promote and administer seasonal influenza vaccine. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated August 3, 2024, revealed that the resident was usually understood, could usually understand, was cognitively impaired, and was dependent on staff for her daily care tasks. Section O0250 A of the MDS (Influenza Vaccination) revealed that the resident did not receive the influenza vaccine in this facility for this year's influenza vaccination season due to being offered but declining the vaccine. Review of Resident 14's clinical record revealed that the resident received the annual influenza vaccine 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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's responsible party was notified about the need to alter treatment or medications for two of eight residents reviewed (Residents 2, 5). Findings include: The facility's policy regarding a change in condition, dated October 24, 2023, indicated that the facility would promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. Unless otherwise instructed by the resident, a nurse would notify the resident's representative when the resident was involved in any accident or incident that resulted in an injury, including injuries of unknown origin; a significant change in the resident's physical, mental, or psychosocial status; a need to change the resident's room assignment; a decision has been made to discharge the resident from the facility; or a transfer to the hospital. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of 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 clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that the resident environment remained free of accident hazards by failing to ensure that a resident's swallowing ability was assessed for potential safety hazards for one of eight residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 8, 2024, revealed that the resident was understood and could understand, had moderately impaired cognition, received a mechanically altered diet, and had no signs or symptoms of a possible swallowing disorder. Physician's orders, dated November 15, 2023, included an order for the resident to receive a mechanical soft, ground texture diet. A nursing note, dated April 2, 2024, at 6:53 p.m. revealed that Licensed Practical Nurse 1 was sitting with Resident 2 during dinner and she asked the resident if he was okay. He did not respond and had no airway exchange. She…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for one of six residents (Resident 2) identified as an elopement risk. Findings include: The facility's policy regarding elopement, dated October 1, 2023, indicated that if staff discovered that a resident was missing from the facility, the facility would determine if the resident was out on an authorized leave or pass, initiate a search of the building and premises; and if the resident is not located, notify the Nursing Home Administrator and the Director of Nursing Services, the resident's legal representative, the attending physician, and law enforcement officials, provide search teams with resident identification information, and initiate an extensive search of the surrounding area. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 24, 2023, indicated that the resident was moderately…

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 staff and resident interviews, it was determined that the facility failed to ensure that meals were served in a manner that maintained or enhanced each resident's dignity by serving meals on the weekends using styrofoam and plastic silverware. Findings include: Residents gathered at a group meeting on October 3, 2023, at 1:00 p.m. indicated that at times weekend meals have been served on styrofoam and with plastic silverware. They further indicated that it was difficult to use the plastic silverware and that it cut the styrofoam plate causing juices from the meal to leak out. Interviews with Nurse Aide 1, Licensed Practical Nurse 2, Licensed Practical Nurse 3, and Nurse Aide 4 on October 3, 2018, from 2:38 p.m. to 2:52 p.m. revealed that they work weekends and have seen weekend meals served on styrofoam plates with plastic silverware. Interview with the Dietary Supervisor on October 4, 2023, at 9:37 a.m. revealed that due to having less staff on the weekends he may use styrofoam and plastic silverware for the main course. He indicated that he comes in on the weekends to…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for two of 46 residents reviewed (Residents 6, 84). Findings include: The facility's policy regarding medication administration, dated October 25, 2022, revealed that medications shall be administered in a safe and timely manner, and as prescribed. Vital signs must be checked/verified for each resident prior to administering medications An admission note, dated September 9, 2023, revealed that Resident 6 was admitted from the hospital and was a newly diagnosed dialysis patient. Resident 6 was alert and oriented to person, place, and time, and she signed all the admission paperwork. Physician's orders for Resident 6, dated September 9, 2023, included an order for the resident to receive 20 milligrams of Omeprazole (a medication for acid reflux) once a day for gastroesophageal reflux disease (GERD). Nephrologist (a doctor who specializes in kidney care) orders for Resident 6, dated September 20, 2023, included an…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food items in the walk-in freezer were properly secured, labeled and dated, and failed to ensure that dietary staff wore hair coverings that completely covered their hair during food handling. Findings include: The facility's policy regarding labeling food, dated October 25, 2022, revealed that each food item, once opened, was to be securely closed, labeled and dated before returning to the freezer. Observations in the walk-in freezer on October 2, 2023, at 10:45 a.m. revealed that there were three mini pizzas, nine pieces of French toast, approximately fifteen pounds of California blend mixed vegetables, 15 frozen hamburger patties, and an approximately fifteen-pound bag of frozen peas that were not tightly secured, labeled or dated. Interview with the Dietary Director on October 2, 2023, at 10:55 a.m. confirmed that all food items were to be secured, dated and labeled. The facility's policy regarding hair restraints, dated October 25, 2022, revealed…

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

Based on a review of policies, as well as interviews with residents and staff, it was determined that the facility failed to ensure that residents and/or their representatives could file a grievance/concern anonymously by failing to ensure that concerns brought to staff were investigated even if the residents did not want their name listed on a form. Findings include: The facility's Resident Suggestion/Concerns/Process policy, dated October 25, 2022, indicated if a resident or family does not want to complete the grievance form, it is the responsibility of the associates hearing the grievance to complete the form and submit it for follow-up and resolution. All associates were responsible for ensuring customer satisfaction within the facility. During an interview with the Social Services Director on October 5, 2023, at 1:07 p.m. and 3:40 p.m., it was revealed that there have been complaints about rude staff on the B wing/rehabilitation wing. However, when she offered to fill out a grievance form, the residents refused. She never filled out an anonymous grievance form before, because…

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 interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for two of 46 residents reviewed (Residents 78, 122). Findings include: The facility's policy regarding care plan development, dated October 25, 2022, included that the facility would develop a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 78, dated September 7, 2023, revealed that the resident had impaired cognition, required assistance with daily care needs, and had diagnoses that included schizophrenia (mental illness that affects behaviors) and dementia. A care plan, dated May 13, 2022, revealed that Resident 78 was an elopement risk. A nursing note for Resident 78,…

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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 46 residents reviewed (Residents 31, 52). Findings include: A facility policy for plans of care, dated July 31, 2023, indicated that resident assessments are ongoing and care plans are revised as information about the resident and their condition changes. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 31, dated July 20, 2023, revealed that the resident was usually understood and could usually understand others, and was independent for daily care needs but required supervision after set up for dressing and physical assistance of staff for bathing. A restorative ambulation care plan for Resident 31, dated May 19, 2020, had an intervention that was initated on April 29, 2021, for the resident to walk 60 feet with a hemi walker during the first shift with a wheelchair to…

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

Based on review of Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an assessment was completed by a professional (registered) nurse after a fall occurred for one of 46 residents reviewed (Resident 38). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The facility's policy for change in condition, dated October 25, 2022, indicated that the nurse will record information in the resident's medical record that is relative to changes in the resident's medical/mental condition or status. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a 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.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were provided proper nail care for one of 46 residents reviewed (Resident 122). Findings include: The facility's policy for shower/tub baths, dated October 25, 2022, indicated that the facility was to promote cleanliness and provide comfort for the resident. The facility's policy for care of fingernails and toenails, dated October 25, 2022, indicated that nail care included daily cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 122, dated July 14, 2023, indicated that he was confused, required extensive assistance of one for dressing and hygiene, and was total dependence of one for bathing. Observations on October 3, 2023, at 12:00 p.m. and on October 4, 2023, at 9:05 a.m. revealed that Resident 122 was in bed and the length 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 the clinical records and facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that pressure ulcer prevention interventions were in place for two of 46 residents reviewed (Residents 72, 122). Findings include: The facility policy for prevention of pressure ulcers, dated October 15, 2023, indicated that the facility was to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. These interventions should be designed to reduce or eliminate those risk fractures. A significant change Minimum Data Set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 72, dated September 18, 2023, indicated that she was cognitively impaired and required the assistance of two staff for bed mobility and extensive assistance of two staff for daily care needs. Physician's orders for Resident 72, dated February 2, 2023, included and order for the resident to wear heel float boots to both feet at all times. Observations…

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, observations, and staff interviews, it was determined that the facility failed to ensure that physician-ordered contracture management services were provided as care planned for one of 46 residents reviewed (Resident 106). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 106, dated July 5, 2023, revealed that the resident was cognitively impaired, required extensive assist for daily care needs, and had diagnoses that included dementia, hemiplegia (one-sided weakness), and stroke. Physician's orders for Resident 106, dated September 8, 2023, included an order for the resident to wear a left resting hand splint to be applied with morning care and removed with evening care. Hygiene was to be provided with application removal. An activities of daily living (ADL- essential and routine tasks that most young, healthy individuals can perform without assistance) care plan for Resident 106, dated July 6, 2023, indicated that the resident was to wear a left-resting…

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 reviews, observations, and staff interviews, it was determined that the facility failed to supervise a resident while eating resulting in a choking episode requiring back blows for one of 46 residents reviewed (Resident 17), and failed to ensure that a resident had effective interventions for fall prevention for one of 46 residents reviewed (Resident 59). Findings include: An annual Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 17, dated July 23, 2023, revealed that the resident was cognitively intact and required extensive assistance of two for daily care needs and supervision for meals, and had diagnoses that included dysphagia (difficulty swallowing). The resident's care plan, dated March 17, 2017, revealed that she required supervision for meals and was to be encouraged to be upright in a chair for meals. A nurse's note for Resident 17, dated June 28, 2023, at 8:59 a.m. revealed that a licensed practical nurse heard staff yelling for help. When responding to the call, the resident was…

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

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide appropriate care for an indwelling urinary catheter for one of 46 residents reviewed (Resident 52). Findings include: The facility policy for urinary catheter care, dated October 22, 2022, indicated that to prevent catheter-associated urinary tract infections the staff are to ensure maintenance of an unobstructed urine flow. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine tubing and drainage bag from flowing back into the urinary bladder. The staff are to ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site (strapped to the resident's inner thigh area). The diagnosis record for Resident 52, dated April 5, 2023, included dementia, anxiety, chronic kidney disease, and absence of a kidney. A quarterly Minimum Data Set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 52, dated July 14, 2023, indicated that…

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

Based on review of clinical records and facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident's respiratory status was properly monitored as ordered and equipment cleaned for three of 46 residents reviewed (Residents 84, 106, 122). Findings include: The facility policy for oxygen administration, dated October 25, 2022, indicated that staff are to verify that there is a physician's order for use and to review the resident's care plan to assess for any special needs of the resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 84, dated August 16, 2023, revealed that the resident was cognitively impaired, required extensive assistance for daily care needs, and had diagnoses that included heart failure and respiratory failure. Physician's orders for Resident 84, dated July 15, 2023, included an order for the resident to receive continuous oxygen at two liters per minute and to monitor oxygen saturations (percent of oxygen in the…

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

Based on clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that a dialysis emergency kit containing appropriate equipment, such as a tourniquet, sterile gauze, gloves, etc., in order to stop bleeding in case the resident's dialysis catheter pulls out or breaks off, was at the resident's bedside per physician's orders and care plans for one of 46 residents reviewed (Resident 6). The findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated September 14, 2023, indicated that the resident was cognitively impaired and required hemodialysis (a process of cleaning the blood of toxins and returning it into the body). Physican's orders, dated September 8, 2023, included an order for the resident to have dialysis emergency equipment at the bedside in order to prevent the resident from bleeding to death if the dialysis port should get pulled out or damaged. Observation of Resident 6 on October 2, 2023, at 1:46 p.m. revealed…

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

Based on review of policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that a resident who displayed problematic wandering behaviors to collect and chew on used cigarette butts received appropriate services for one of 46 residents reviewed (Resident 78). Findings include: The facility's behavior management program, dated October 25, 2022, included that the facility will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 78, dated September 7, 2023, revealed that the resident had impaired cognition, required assistance with daily care needs, and had diagnoses that included schizophrenia (mental illness that affects behaviors) and dementia. A care plan, dated May…

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 policies and clinical records, medication manufacture instructions, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled/dated for one of 46 residents reviewed (Resident 138) and failed to ensure that vials of antibiotic were properly labeled. Findings include: The facility policy for labeling medications, dated October 25, 2022, indicated that all medications maintained in the facility shall be properly labeled in accordance with the current state and federal regulations. The most current manufacturer's instruction for insulin Basaglar (a long acting insulin) indicated that the prefilled pens in use must be used within 28 days or be discarded, even if they still contain insulin. Physician's orders for Resident 138, dated July 24, 2023, included an order for 10 units of Basaglar KwikPen (Pen-injector) subcutaneously (directly under the skin) at bedtime for diabetes. Observations on October 23, 2023, at 12:05 p.m. of the medication cart on the 100 nursing unit revealed that there…

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, clinical record reviews, observations, and staff and resident interviews, it was determined that the facility failed to honor food preferences for one of 46 residents reviewed (Resident 116). Findings include: The facility's policy regarding nutrition services, dated October 25, 2022, indicated that the facility would assess individual food preferences upon admission and modifications to the diet would only be ordered with the resident or representative's consent. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 116, dated July 1, 2023, indicated that the resident was severely cognitively impaired, was independent with care, and was independent with eating after set up. A nutritional care plan for Resident 116, dated May 11, 2021, indicated that the resident was at risk for actual and potential weight loss/gain related to behavior, obesity, Type II diabetes, medication use, need for therapeutic diet, and radiation treatment related to brain tumor with decreased appetite.…

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, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 46 residents reviewed (Resident 114). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 114, dated September 3, 2023, revealed that the resident was severely cognitively impaired, required extensive assistance with daily care needs, and had a Stage 2 pressure ulcer (a wound caused by pressure) that was not present on entry or reentry to the facility. A nursing note for Resident 114, dated July 24, 2023, indicated that a Stage 2 pressure ulcer was observed measuring 0.5 centimeters (cm) by 0.5 cm. The wound was cleansed with normal saline, Triad cream applied, and the site was covered with a bordered foam dressing. A care plan for Resident 114 regarding an actual Stage 2 pressure ulcer, dated July 26, 2023, revealed that it was resolved on September 19, 2023. Physician's orders for Resident 114, 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.

Based on review of hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two of 46 residents reviewed (Residents 28, 122). Findings include: An agreement between the facility and a hospice provider (provider of end-of-life services), dated May 19, 2022, indicated that the hospice provider would provide the following information to the facility: a hospice election form (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness) and any advance directive specific to each resident. Copies of all physician orders provided to the nursing facility will be in writing and signed by the attending physician or the hospice physician. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 28, dated September 21, 2023, revealed that 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 the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficient practices. Findings include: The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending October 6, 2022; January 18, 2023; February 9, 2023; March 20, 2023; June 26, 2023; and July 25, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending October 5, 2023, identified repeated deficiencies related to grievances, updating and revising care plans, accident hazards, kitchen sanitation, accurate and complete resident records, and infection control. The facility's plans of correction 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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow CDC guidelines to reduce the spread of infections and prevent cross-contamination for one of 46 residents reviewed (Resident 19) who had an Extended Spectrum Beta-Lactamase (ESBL - enzymes produced by bacteria that may make them resistant to some antibiotics) infection in the urine, and failed to use proper infection control practices during incontinent care for one of 46 residents reviewed (Resident 44). Findings include: The facility's Infection Prevention and Control policy, dated October 25, 2022, revealed that transmission-based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated September 22, 2023, revealed that the resident was cognitively impaired, required extensive…

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.