Susquehanna Health And Wellness Center

Based upon review of facility policy and procedure, observation and clinical record review, it was determined that the facility failed to ensure proper infection control procedures were followed during medication administration observation and pressure ulcer wound treatments for three of three residents observed (Resident 6, Resident 22 and Resident 136.)Findings include: Review of facility policy and procedure titled Administering Medications revealed “Staff follows established facility infection control procedures (e.g. handwashing, aseptic technique, gloves, isolation precautions, etc) for the administration of medications, as applicable.” Observation of Medication Administration on July 22, 2025, at 11:44 a.m. revealed Licensed Employee E9 placing medication pills for administration into Licensed Employee E9’s ungloved hands and then placing the medication pill into the medication cup for administration. Observations on all days of the survey revealed no system in place to communicate to staff that resident required enhanced barrier precautions. Additionally, no PPE (personal…

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

Based on observations, clinical record review and staff interview it was determined that the facility failed to develop a comprehensive care plan for one of 32 residents reviewed (Resident 1).Findings include:Observations on July 22, 2025, at 2:20 p.m. and July 24, 2025, at 12:00 p.m. revealed Resident 1 receiving oxygen via nasal cannula.Review of Resident 1's clinical record revealed no care plan for oxygen use.Interview with the Director of Nursing on July 25, 2025, at 11:23 a.m. confirmed that Resident 1 did not have a care plan for oxygen use.483.21 Develop/Implement Comprehensive Care PlanPreviously cited 8/22/2428 Pa. Code 211.12(d)(1)(5) Nursing ServicesPreviously cited 8/22/24

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records and staff interviews, it was determined that the facility failed to maintain acceptable parameters of nutritional status for two of three residents reviewed (Residents 4 and 22). Findings include:Review of facility policy, Weight Assessment and Intervention revised September 2008, revealed monthly weights will be completed no later than the 7th day of the month. Additionally, any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation.Review of Resident 4's clinical record revealed that the resident weighed 150.0 pounds on April 28, 2025. The resident was admitted to the hospital on [DATE], and readmitted to the facility on [DATE].Review of a weight warning note on May 9, 2025, revealed a weight of 181.3 pounds and indicated a suspected discrepancy in weight. A reweight was requested. Review of the clinical record revealed a reweight of 135.0 pounds was obtained on May 20, 2025 (11 days…

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

Based on observations, clinical record review and staff interview it was determined that the facility failed to ensure respiratory care was provided consistent with professional standards of practice for one of one resident reviewed (Resident 1).Findings include:Observations on July 22, 2025, at 2:20 p.m. and July 24, 2025, at 12:00 p.m. revealed Resident 1 receiving oxygen via nasal cannula (tube that delivers oxygen) at a flow rate of 2.0 liters per minute.Review of Resident 1's clinical record revealed no order for oxygen or respiratory care.Interview with the Director of Nursing on July 25, 2025, at 11:23 a.m. confirmed that Resident 1 did not have an order for oxygen use.483.25 Respiratory/Tracheostomy Care and SuctioningPreviously cited 3/5/25, 8/22/2428 Pa. Code 211.12(d)(3)(5) Nursing ServicesPreviously cited 8/22/24

Based upon observation, it was determined that the facility failed to ensure adequate and competent staffing levels were maintained to promptly respond to resident call bells on one day of three days of the survey.Findings include:Observation on July 23, 2025, at 12:07 p.m. on the B Wing nursing unit revealed five resident call bells with the lights on and audibly ringing, as well as lunch carts in the hallway that had been delivered to the unit from the kitchen.Observation of the B Wing nursing unit nurses' station on July 23, 2025, at 12:07 p.m. revealed four employees gathered in a side room with the door closed.Further observation of the B Wing nursing unit nurses' station on July 23, 2025, at 12:07 p.m. revealed a licensed employee sleeping in front of the computer at the desk.Observation of the B Wing resident call bells revealed the resident call bells remained unanswered and the lunch trays not delivered for approximately 15 minutes.The above information was conveyed to the Nursing Home Administrator and Director of Nursing on July 25, 2025, at 11:30 a.m. 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.

Based on review of facility policies and procedures and observation, it was determined that the facility failed to ensure medications were properly labeled with open and expiration dates and failed to ensure expired medications were not administered for one of three medication carts reviewed (B Wing Medication Cart).Findings include:Based upon facility policy and procedure titled Storage of Medications revealed Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.Review of facility policy and procedure titled Administering Medications revealed The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.Review of package insert instructions for Humalog Insulin (medication used to treat high blood sugar levels) Pens revealed unopened Humalog pens should be stored in the refrigerator.Further review of package insert instructions for Humalog Insulin Pens revealed that once opened, Humalog can be kept at room…

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 observation, clinical record review, hospital record review, and resident and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and follow the physician's orders for two of the two residents reviewed (Resident CL1 and Resident 1). Findings include: A review of Resident CL1's hospital records dated February 2, 2025, revealed that the resident was sent to the hospital on January 26, 2025, for shortness of breath and was admitted with a diagnosis of Acute Respiratory Failure. The same report revealed that the Resident was using a BIPAP (a non-invasive ventilator technique that provides pressurized air to assist with breathing) in the hospital. A review of the hospital record BIPAP order dated February 10, 2025, revealed Auto Bipap Max-18 Min-5 PS-5 for associated diagnosis of Acute Respiratory Failure and Obstructive Sleep Apnea (A potentially serious sleep disorder in which breathing repeatedly stops and starts). A review of the hospital discharge summary…

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 notify the resident and resident's representative, in writing, regarding the reason for hospitalization for five of 56 residents reviewed (Residents 18, 36, 38, 77, 85). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 18, dated June 17, 2024, indicated that the resident was cognitively impaired, required assistance from staff for his daily care needs, and had diagnoses that included dementia. A nursing note for Resident 18, dated June 11, 2024, revealed that the resident was transferred to the hospital for evaluation of abdominal pain and to have his indwelling urinary catheter flushed or replaced. He was admitted to the hospital with a urinary tract infection. There was no documented evidence that a written notice of Resident 18's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer. A quarterly MDS assessment for Resident 36,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for seven of 56 residents reviewed (Residents 28, 52, 53, 91, 94, 139, 162). Findings include: The Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated [DATE], revealed that Section O0110G1b (non-invasive mechanical ventilator) was to be checked if a CPAP/BIPAP device (respiratory support devices that prevent airways from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle) was used while a resident within the last 14 days. Physician's orders for Resident 28, dated [DATE], included an order for the resident to use a CPAP/BIPAP with distilled…

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, 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 six of 56 residents reviewed (Residents 8, 25, 27, 38, 53, 120). Findings include: A facility policy for Comprehensive Person-Centered Care Plans, dated June 1, 2024, included that the interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each person. The comprehensive, person-centered care plan was to be developed within seven days of the completion of the required MDS assessment (admission, annual or change in significant status), and no more than 21 days after admission. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs)…

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 physicians orders were followed for three of 56 residents reviewed (Residents 104, 112, 139). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 104, dated June 14, 2024, indicated that the resident was understood and able to understand others, was dependent on staff for personal hygiene care, and had diagnoses that included cancer and anxiety. Physician's orders for Resident 104, dated June 29, 2024, and August 5, 2024, included an order for the resident to receive 150 milligrams (mg) of Depo-Provera (a medication containing hormones that has been found effective in reducing offensive sexual behavior) intramuscularly one time a day every seven days for impulse disorder. Review of the Medication Administration Record (MAR) for Resident 104 for July 2024 revealed no documented evidence that the resident was administered the Depo-Provera injection as ordered 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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for two of 56 residents reviewed (Residents 109, 125) and failed to protect the safety of other residents from violence from two of 56 residents reviewed (Residents 52, 85). Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 109, dated May 15, 2024, revealed that the resident was cognitively intact and required extensive assistance for daily care needs including transfers and locomotion. Observations of Resident 109 on August 19, 2024, at 12:28 p.m. revealed that the resident was sitting in a wheelchair while being transported to her room by Nurse Aide 2. There were no footrests on her wheelchair to prevent her feet from dragging during the transport. An interview with Nurse Aide 2 revealed that he did not know if she had leg rests or not and did not know if she needed them. An interview with the…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for two of 56 residents reviewed (Residents 8, 56). Findings include: The facility's policy regarding medication administration, dated June 1, 2024, indicated that medications are administered in accordance with prescriber orders, including any required time frame. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated July 17, 2024, revealed that the resident was cognitively impaired, was dependent on staff for personal care needs, and had diagnosis that included diabetes. Nurse's note for Resident 8, dated August 16, 2024, indicated that a new physician's order was obtained to decrease the resident's Levemir (type of long-acting insulin used to lower blood sugar) to 33 units every day. Physician's orders for Resident 8, dated August 16, 2024, included an order to discontinue giving 35 units of Levemir insulin once…

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 and interviews with residents and staff, it was determined that the facility failed to serve food that was palatable to residents. Findings include: Interviews on August 19, 2024, with Resident 28 at 12:17 p.m. and Resident 56 at 12:22 p.m. revealed that the food was terrible and a little rough. The posted menu for August 20, 2024, revealed that the lunch meal was chicken teriyaki, fluffy steamed rice, seasoned broccoli, and sherbet. Observations in the kitchen on August 20, 2024, at 11:57 p.m. revealed that a test tray was placed on the lunch meal cart going to the A wing. The cart arrived on the unit at 11:59 p.m., and the last resident was served and eating at 12:15 p.m. At 12:15 p.m. the temperature of the chicken teriyaki was 131.7 degrees Fahrenheit (F) and was dry, and the temperature of the seasoned broccoli was 134.7 degrees F and it was mushy. Interview with the Dietary Manager on August 20, 2024, at 12:15 p.m. confirmed that the chicken appeared dry and the broccoli was mushy and over-cooked. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored and served in accordance with professional standards for food service safety and failed to effectively sanitize dishes during mechanical dishwashing. Findings include: The facility's policy for food storage, dated June 1, 2024, revealed that leftover food was to be stored in covered containers or wrapped carefully and securely, and each item was to be clearly labeled and dated before being refrigerated. Observations of the walk-in refrigerator and dry storage area on August 19, 2024, at 8:45 a.m. revealed that there were two Styrofoam containers that contained cooked eggs/omelets that were not dated or labeled, and one gallon of corn syrup that was open without a lid. Interview with the Dietary Manager on August 19, 2024, at 8:45 a.m. confirmed that staff should have labeled and dated the Styrofoam containers of eggs and she was not sure why there was no lid on the gallon of corn syrup in the dry storage area. Observations in the main…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for three of 56 residents reviewed (Residents 94, 98, 112). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 94, dated July 10, 2024, revealed that the resident could usually make herself understood and understand others, was cognitively impaired, and had diagnoses that included dementia and a stroke. Nurse aide documentation for Resident 94 for June, July and August 2024 revealed that staff were documenting every shift that the resident was wearing a wander bracelet (alarming device) June 14 through August 20, 2024. Observations of Resident 94 on August 20, 2024, at 11:06 a.m. revealed that the resident was sitting in her wheelchair and did not have a wander bracelet (alarming device) on. 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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide care in a manner that maintained dignity for one of 56 residents reviewed (Resident 48). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 48, dated August 6, 2024, indicated that the resident was understood and able to understand others, required substantial to moderate assistance with personal hygiene care, and had diagnoses that included diabetes. Observations of Resident 48 on August 19, 2024, at 11:00 a.m. revealed that she was lying in her bed with many long, white hairs protruding from under her chin. An interview with Resident 48 at that time revealed that she does not like having the long hair on her chin because it sometimes gets caught on her blankets and pulls her skin. Observations of Resident 48 on August 21, 2024, at 7:47 a.m. and on August 22, 2024, at 12:07 p.m. revealed that the resident continued to have many long, white hairs protruding from under…

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 clinical records, as well as staff interviews, it was determined that the facility failed to determine a resident's preference for bathing for one of 56 residents reviewed (Resident 48). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 48, dated August 6, 2024, indicated that the resident was understood and able to understand others; required substantial to moderate assistance with personal hygiene care; had a preference that was was very important to her to choose between a tub bath, shower, bed bath, or sponge bath; and had diagnoses that included diabetes. Review of the care plan for Resident 48, dated August 2, 2024, revealed that the resident required assist of one staff for bathing; however, it did not indicate if the resident preferred showers, tub baths or bed baths. Interview with the Director of Nursing on August 22, 2024, at 2:10 p.m. revealed that there was no documented evidence that Resident 48's shower preferences were identified to enable staff 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 clinical record reviews and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that in preparation for room changes each resident received written notice, including the reason for the change, before the resident's room or roommate was changed for one of 56 residents reviewed (Resident 139). Findings include: Review of Resident 139's clinical record and quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 139, dated July 1, 2024, revealed that the resident could understand others and make herself understood and was cognitively intact. A social service note, dated August 12, 2024, at 9:45 a.m., revealed that Resident 139 toured the A-unit, was introduced to several nursing staff on the unit, and was in agreement with the room at that time. A facility census report revealed that Resident 139 was moved from the B-wing to a room on the A unit on August 12, 2024. There was no documented evidence that Resident 139 was provided a written notice prior 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for nine of 56 residents reviewed (Residents 22, 82, 112, 120, 131, 136, 153, 155, 157). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October, 2023, indicated that an admission MDS assessment was to be completed no later than 14 days (admission date + 13 calendar days) following admission. A comprehensive admission MDS assessment for Resident 22, dated June 27, 2024, revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on July 9, 2024, which…

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

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that Quarterly Minimum Data Set assessments were completed within the required timeframe for seven of 56 residents reviewed (Residents 21, 26, 64, 70, 98, 139, 148). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of residents' abilities and care needs), dated October 2019, indicated that the completion date for a quarterly assessment is the Assessment Reference Date (ARD - the last day of an assessment's look-back period) plus 14 days. A quarterly assessment is due every 92 days (ARD of most recent assessment + 92 days). A quarterly MDS assessment for Resident 21, with an ARD of May 10, 2024, was completed on May 27, 2024, which was three days late. A quarterly MDS assessment for Resident 26, with an ARD of May 10, 2024, was completed on 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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to obtain physician's orders for the administration of oxygen for one of 56 residents reviewed (Resident 139). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 139, dated July 1, 2024, revealed that the resident was cognitively intact, had medical diagnoses that included heart failure and respiratory failure, and used oxygen. The resident's care plan, dated March 7, 2024, revealed that staff were to administer oxygen as ordered by the physician. Observations on August 19, 2024, at 12:11 p.m. revealed that Resident 139 was receiving oxygen via nasal cannula (tube that delivers oxygen) set at a flow rate of 2.0 liters per minute. There was no documented evidence that a physician's order was received for the administration of oxygen. Interview with the Nursing Home Administrator on August 21, 2024, at 3:23 p.m. confirmed that there was no physician's order for Resident 139 to receive…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 56 residents reviewed (Residents 36, 94, 116). Findings include: A facility policy for medication administration, dated June 1, 2024, indicated that the individual administering a medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated July 23, 2024, indicated that the resident was understood and able to understand others, required substantial to maximum assistance for his daily care needs, and had diagnoses that included dementia. Physician's orders for Resident 36, dated June 15, 2024, and July 17, 2024, included to administer 50 milligrams (mg) of Tramadol (a controlled medication use to treat pain) every eight hours as needed for right shoulder or…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to label medications with the date they were opened in one of two medication rooms reviewed (A unit) and in two of four medication carts reviewed (A and B unit). Findings include: The facility's policy regarding medication storage/labeling, dated June 1, 2024, indicated that multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. An undated package insert for Tubersol (used to test for tuberculosis - a bacterial infection) revealed that once entered/opened, the vial was to be discarded after 30 days. Observations in the medication room refrigerator on the A unit on August 22, 2024, at 12:18 p.m. revealed that an opened vial of Tubersol was not properly labeled with the date it was opened. An interview with Registered Nurse 1 at that time confirmed that the opened vial of Tubersol was not properly labeled with the date it was opened and should have been.…

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 established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for three of 56 residents reviewed (Residents 25, 77, 94). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission 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 clinical record review and staff interview, it was determined that the facility failed to ensure Resident R8's care plan was comprehensive including mental health diagnosis and associated behaviors for one of eight residents reviewed (Resident R8). Findings include: Review of the clinical record for Resident R8 revealed the following diagnoses: Schizophrenia (serious mental illness which impacts a person's ability to perceive the world around them in the same way) and Major Depressive Disorder (mental health disorder characterized by low self-esteem, loss of interest in normally enjoyable activities, low energy, and pain without a clear cause). Review of Resident R8's clinical record failed to reveal a care plan goal/interventions for Schizophrenia indicating that the resident should be monitored for mental health associated behaviors and side effects of medication. An interview with the Director of Nursing (DON) on August 23, 2023, at 1:15 p.m. revealed that the facility was not documenting the residents behaviors and did not have a care plan for the medication. 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.