Caring Heights Community Care & Rehab Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Minimum Data Set (MDS-periodic assessment of resident care needs) User's Manual, clinical record, and staff interview, it was determined that the facility failed to complete a comprehensive assessment after a significant change in condition for one of three residents reviewed receiving hospice services (Resident R25).Findings include: Review of the MDS User's Manual revealed that a significant change in status assessment is required to be performed when a terminally ill resident enrolls in a hospice program and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14-days from effective date of the hospice election. Review of the admission record indicated Resident R25 was admitted to the facility on [DATE]. Review of Resident R25's MDS dated [DATE], indicated the diagnoses of hypothyroidism (condition where the thyroid gland doesn't produce enough thyroid hormone, leading to a slowdown in metabolism), congestive heart failure (syndrome caused by an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for two of three residents (Residents R7 and R79). Findings include: The 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 October 2024, indicated the following instructions: Section N0415: High-Risk Drug Classes: Use and Indication, Question N0415E1 - Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 day). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan for anxiety for one of three residents (Resident R8).Findings include:Review of facility policy Comprehensive Care Planning Policy dated 8/1/25, and previously dated 7/1/24, indicated that the facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessments. These plan s will be focused on resident choices, abilities with the intent of maintaining or improving resident functional abilities and quality of life. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE].Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/10/25, indicated diagnoses of high blood pressure, atrial fibrillation (disease of the heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care by failing to implement the facility's hypoglycemia (low blood sugar) protocol and failing to notify the physician timely of a change in condition for one of three residents reviewed (Resident R132).Findings include: Review of facility policy Hypoglycemia dated 8/1/25, indicated nursing personnel are responsible for recognizing signs and symptoms of hypoglycemia and responding accordingly. In the absence of specific treatment orders for hypoglycemia, this protocol will be followed. Monitor for symptoms of hypoglycemia. Symptoms may include: - Weakness or dizziness - Tremor, Palpitations, Sweating - Hunger, Altered Mental Status - Facial Pallor, Hunger - Numbness, Tingling, Drowsiness - Anxiety, AgitationA blood glucose of 70 mg/dL or less may indicate the need for intervention. If there are no provider orders for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive resident-specific plan of care for a resident with limited mobility requiring equipment and assistance to maintain or improve mobility for two of three residents (Resident R93 and R103).Findings include: Review of facility policy Comprehensive Care Planning dated 8/1/25, previously dated 7/1/25, indicated the facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. These plans will be focused on resident choices and abilities with the intent of maintaining or improving resident functional abilities and quality of life. Review of the clinical record revealed that Resident R93 was admitted to the facility on [DATE]. Review of Resident 93's MDS (Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of four residents (Resident R50). Findings include: Review of facility policy Oxygen Administration dated 8/1/25, indicated licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered. Cleaning: Change tubing, mask, cannula weekly and document. Review of the clinical record indicated Resident R50 was admitted to the facility on [DATE]. Review of Resident R50's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/14/25, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), anxiety, and respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide, leading to insufficient oxygenation of the body's tissues). MDS Section O-Special treatments, procedures and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R15). Findings include: Review of the facility policy Social Services dated 8/1/25, indicated the facility provides social services to assure that each resident can attain or maintain his/her highest practical be physical, mental and psychosocial well-being. Social Services will assist in implementing interventions for the resident's needs by developing and maintaining care plans which are individualized, realistic, with measurable goals, including Trauma and PTSD. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE]. Review of Resident R15's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/3/25, indicated diagnoses of Post Traumatic Stress Disorder (PTSD- a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of four residents reviewed (Resident R7).Findings include:Review of facility policy Dementia Care Services dated 8/1/25, previously dated 7/1/24, indicated our nursing home residents who are diagnosed with Alzheimer's/other forms of dementia or who display such symptoms will receive the appropriate treatment and services to attain or maintain his/her highest practicable physical/mental/psychosocial wellbeing. Staff will be familiar with dementia care approaches and each resident's person-centered care plan. Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2024, indicated that a Brief Interview for Mental Status ( BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively…

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

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies in one of two medication rooms (East Wing Medication Room).Findings:Review of facility Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles policy dated 8/1/25, indicated the policy sets for the procedures relating to the storage and expiration dates of medications, biologicals, syringes, and needles. The facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. During a medication storage room review on 9/3/25, at 1:27 p.m. the following were observed:- - Five 21-gauge needles with an expiration date of 4/30/25During an interview on 9/3/25, at 1:32 p.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the above findings. During an interview on 9/3/25, at 2:45 p.m. the Director of Nursing confirmed that the facility failed to properly store medical supplies in one of two medication rooms (East Wing Medication Room).28 Pa Code: 211.9…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observation, and staff interviews, it was determined that the facility failed to provide drinks in a form to meet individuals' needs in one of two residents (Resident R10).Findings include: Review of the facility policy Physician/Provider Orders dated 8/1/25, indicated that the charge nurse shall transcribe and review all physician or provider orders. Orders shall include diet, including nutritional supplements. Review of the clinical record revealed that Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 7/22/25, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section K Swallowing Nutritional Status K0520 C indicated mechanical altered diet and was check marked -while a resident. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for two of four residents (Resident R16, and R22).Findings include: Review of facility policy Hospice Care Policy dated 8/1/25, and previously dated 7/1/24, indicated that hospice services and those providing them will meet professional standards and be provided timely. The facility will ensure that the resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. The facility will designate a team member with a clinical background to work with hospice representative(s) to coordinate the care provided to the community's residents by the hospice staff and the community staff. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, review of clinical record, observations, and staff interviews, it was determined that the facility failed to maintain proper infection control practices related to the care of indwelling urinary catheters (tube inserted in the bladder to drain urine) for one of four residents (Resident R87), and failed to use Personal Protective Equipment (PPE) appropriately in Enhanced Barrier Precautions (EBP-a type of isolation), which created the potential for the cross-contamination and the spread of diseases and infections for one of three residents (R87). Findings include: Review of facility policy Indwelling Urinary Catheter dated 8/1/25, indicated that clinical staff may provide urinary catheter care. Such care will help to prevent catheter association urinary tract infections. Check drainage tubing and bag to ensure that the catheter is draining properly, and no kinks are present. The urinary drainage bag must be placed below the bladder level but not on the floor. Ensure drainage…

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

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Communication training to one of five direct care facility staff reviewed (Employee E4). Findings include: Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the resident's physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations. During an interview on 9/3/2025, at 10:15 a.m. Director of Nursing stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2024 revealed the following concerns: Review of Nurse Aide (NA) Employee E4's facility provided information did not include training on effective communication. During an interview on 9/3/25, at 1:15 p.m. the Director of Nursing confirmed that the facility failed to provide Communication training 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 job description, facility documents and staff interviews, it was determined that the facility failed to provide Resident Rights training to two of five direct care facility staff reviewed (Employee E4 and E5). Findings include: Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the resident's physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations. During an interview on 9/3/2025, at 10:15 a.m. Director of Nursing stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2024 revealed the following concerns: Review of Nurse Aide (NA) Employee E4's facility provided information did not include training on Resident Rights. Review of NA Employee E5's facility provided information did not include training on Resident Rights. During an interview on 9/3/25, at 1:15…

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

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Abuse, Neglect, and Exploitation training to one of five direct care facility staff reviewed (Employee E4). Findings include: Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the resident's physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations. During an interview on 9/3/2025, at 10:15 a.m. Director of Nursing stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2024 revealed the following concerns: Review of Nurse Aide (NA) Employee E4's facility provided information did not include training on Abuse. Neglect, and Exploitation. During an interview on 9/3/25, at 1:15 p.m. the Director of Nursing confirmed that the facility failed to provide…

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

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to two of five direct care facility staff reviewed (Employee E3 and E4). Findings include: Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the resident's physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations. During an interview on 9/3/2025, at 10:15 a.m. Director of Nursing stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2024 revealed the following concerns: Review of Nurse Aide (NA) Employee E3's facility provided information did not include training on QAPI. Review of Nurse Aide (NA) Employee E4's facility provided information did not include training on QAPI. During an…

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

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Infection Control training to one of five direct care facility staff reviewed (Employee E4). Findings include: Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the resident's physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations. During an interview on 9/3/2025, at 10:15 a.m. Director of Nursing stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2024 revealed the following concerns: Review of Nurse Aide (NA) Employee E4's facility provided information did not include training on Infection Control. During an interview on 9/3/25, at 1:15 p.m. the Director of Nursing confirmed that the facility failed to provide Infection Control training 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 job description, facility documents and staff interviews, it was determined that the facility failed to provide Compliance and Ethics training to two of five direct care facility staff reviewed (Employee E4 and E5). Findings include: Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the resident's physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations. During an interview on 9/3/2025, at 10:15 a.m. Director of Nursing stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2024 revealed the following concerns: Review of Nurse Aide (NA) Employee E4's facility provided information did not include training on Compliance and Ethics. Review of NA Employee E5's facility provided information did not include training on Compliance and Ethics. During an interview…

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

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to conduct the minimum 12 hours of nurse aide (NA) training per year for one of five direct care facility staff reviewed (NA Employee E4). Findings include: Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the resident's physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations. During an interview on 9/3/2025, at 10:15 a.m. Director of Nursing stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2024 revealed the following concerns: Review of NA Employee E4's facility provided information included a total of 0.21 hours of annual training. Review of NA Employee E4's facility provided information did not include the minimum 12-hour NA training. During an…

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

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Behavioral Health training to one of five direct care facility staff reviewed (Employee E4). Findings include: Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the resident's physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations. During an interview on 9/3/2025, at 10:15 a.m. Director of Nursing stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2024 revealed the following concerns: Review of Nurse Aide (NA) Employee E4's facility provided information did not include training on Behavioral Health. During an interview on 9/3/25, at 1:15 p.m. the Director of Nursing confirmed that the facility failed to provide Behavioral Health training 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for four of four residents (Residents R14, R49, R59, R120). Findings include: Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R14's MDS (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 7/19/24, indicated diagnoses of adult failure to thrive, high blood pressure, and atrial fibrillation (irregular heart beat). Review of the clinical record indicated Resident R14 was transferred to hospital on 9/15/24, and returned to the facility on 9/19/24. Review of Resident R14's clinical record and facility documents indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for the transfer 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for four of four resident hospital transfers (Resident R14, R49, R59, and R120). Findings Include: Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R14's MDS (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 7/19/24, indicated diagnoses of adult failure to thrive, high blood pressure, and atrial fibrillation (irregular heart beat). Review of the clinical record indicated Resident R14 was transferred to hospital on 9/15/24, and returned to the facility on 9/19/24. Review of Resident R14's clinical record and facility documents failed to include documented evidence that the resident or 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 a review of the RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for two of eight residents (Residents R68, and R114). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of resident care needs), dated October 2024, indicated the following: -Section O 1. Code 0, no: if the resident ' s pneumococcal vaccination status is not up to date or cannot be determined. Proceed to item O0300B, If Pneumococcal vaccine not received, state reason. 2. Code 1, yes: if the resident ' s pneumococcal vaccination status is up to date. Skip to O0350. Review of the admission record indicated Resident R68 admitted to the facility on [DATE]. Review of Resident R68's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/1/24, indicated the diagnoses of anemia (the blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, and interviews with staff, it was determined that the facility failed to promote and protect a resident's dignity for one out of three residents reviewed (Resident R38). Findings include: Review of Resident R38's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses of transient cerebral ischemic attack (a temporary blockage of blood flow to the brain, usually caused by a blood clot.), muscle weakness, and cerebrovascular disease (condition that affect blood flow to your brain). Review of Resident R38's physician order dated 11/11/23, indicated a regular puree diet order with nectar thick liquid. Review of Resident R38's Minimum Data Set (MDS - periodic assessment of care needs) dated 9/7/24, indicated the diagnoses were current. During an observation on 10/21/24, at 10:01 a.m. a sign was observed posted on Resident R38's head board that stated Nectar Thick. During an observation and interview on 10/22/24, at 11:57 a.m.…

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 resident personal fund accounting, clinical record review and resident and staff interview, it was determined that the facility failed to provide a resident funds quarterly statement for five of eight residents reviewed for personal funds concerns (Resident R2, R30, R67, R99 and R94). Findings include: During resident group indicated they did not know how much money they had and do not receive financial statements. Interview with Resident R2 on 10/22/24, at 11:30 a.m., revealed that she did not receive any financial statements pertaining to her personal fund account. Resident R2 denied that she had any family or individuals who assisted her to manage her finances. Interview with Business Office Manager E11 on 10/23/24 at 1:00 p.m. revealed that she knows those statements are an issue. Interview with the Nursing Home Administrator (NHA) on 10/24/24 at 11:30 a.m. revealed that the statements come from their corporate office in Ohio and she could not provide proof of who received them and what time frame. NHA confirmed there is no evidence that the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify a physician for a change in condition for one of five residents (Resident R14). Findings include: Review of the clinical record indicated that Resident R14 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnosis that included Friedreich ataxia (a rare genetic condition that causes progressive nervous system damage and movement issues), heart failure (condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), and atrial fibrillation (irregular and often faster heartbeat). An MDS (Minimum Data Set- periodic assessment of care needs) dated 7/12/24, indicated the diagnoses remain current. Review of Resident R14's care plan dated 4/16/24, indicated to observe resident for non-verbal signs of distress. Review of Resident R14's care plan dated 7/9/24, indicated the resident is at risk for pain related 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 a review of facility admission documents and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the Notice of Medicare Non-Coverage (NOMNC) form for one of three residents (Resident R105) and failed to ensure NOMNC notices were provided timely for one of three residents (Resident R321). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019 indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R105's admission record indicated the resident was admitted to the facility 9/28/24. Review of Resident R105's demographic information available in the electronic medical record indicated that Resident R105's spouse was the emergency and…

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

Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for five of twelve residents (Residents R21, R59, R68, R84, R97). Findings include: Review of Title 42 Code of Federal Regulations §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. A facility tour with Maintenance Director Employee E9 on 10/25/24, at 10:00 a.m. revealed five resident rooms had deep gouges behind the head of the bed. Resident R21, R59, R68, R84 and R97. Two resident rooms had sticky, debris, and grime on the floor under the bedside table, and between the door and window beds. The base of Resident R68's tube feeding pole was corroded with dried tube feed formula. An interview on 10/25/24, at 10:00 a.m. the Maintenance Director…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, facility documents, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain residents were free from abuse and neglect for two of three residents (Resident R57 and R84). Findings include: Review of facility policy Abuse, Neglect and Exploitation dated 7/1/24, indicated neglect as the failure of the facility, its employees or service providers to provide goods and services to resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the admission record indicated Resident R57 admitted to the facility on [DATE]. Review of Resident R57's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/2/24, indicated the diagnoses of multiple sclerosis (immune system eats away at protective covering of nerve cells), peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), and coronary artery disease (narrow arteries…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility incident documents, resident, and staff interviews, it was determined that the facility failed to report an alleged allegation of neglect for one of three residents (Resident R57). Findings include: Review of facility policy Abuse, Neglect and Exploitation dated 7/1/24, indicated facility staff must immediately report all abuse allegations to the Administrator. The Administrator will notify the applicable local and state agencies. Review of the admission record indicated Resident R57 admitted to the facility on [DATE]. Review of Resident R57's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/2/24, indicated the diagnoses of multiple sclerosis (immune system eats away at protective covering of nerve cells), peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), and coronary artery disease (narrow arteries decreasing blood flow to heart). Section GG0170 indicated dependent for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to investigate an allegation of abuse/neglect for one of three residents (Resident R57). Findings include: Review of facility policy Abuse, Neglect and Exploitation dated 7/1/24, indicated once the Administrator and Department of Health are notified, an investigation of the allegation will be conducted and completed within five days of the alleged occurrence. Review of the admission record indicated Resident R57 admitted to the facility on [DATE]. Review of Resident R57's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/2/24, indicated the diagnoses of multiple sclerosis (immune system eats away at protective covering of nerve cells), peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), and coronary artery disease (narrow arteries decreasing blood flow to heart). Section GG0170 indicated dependent for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two out of four residents sampled with facility-initiated transfer (Residents R49 and R59). Findings include: Review of Resident R59's admission record indicated he was originally admitted on [DATE], with diagnoses that included heart failure, obesity and dysphagia (difficulty swallowing). Review of Resident R59's clinical record revealed that the resident was transferred to the hospital on 4/15/24, and returned to the facility on 4/17/24. Review of Resident R59's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain that residents received the necessary services, consistent with professional standards of practice to promote healing and prevent infection for one of four residents (Residents R26). Findings include: Review of the facility Pressure Injury Prevention and Treatment Policy dated 9/18/23, last reviewed 7/1/24, indicated residents admitted with existing pressure injuries will receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. Pressure injuries identified will be assessed initially and at least weekly thereafter. Pressure injuries will be documented and orders obtained from providers for treatment. Review of the facility Comprehensive Care Planning Policy dated 7/1/24, last indicated a baseline care plan must be developed within 48 hours of admission to insure that the resident's needs are met…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide adequate assistance during a transfer for one of six residents (Resident R102), which resulted in a laceration of right lower extremity that required 15 sutures for Resident R102. Findings include: Review of the facility Incident/ Accident Policy dated 7/1/24, indicated an incident/accident is any occurrence which is not consistent with the routine care of a particular resident An incident/ accident can occur anywhere and be discovered by anyone. All incident/accidents involving residents will be analyzed and reported. Review of Resident R102's admission record indicated he was admitted to the facility on [DATE]. Review of Resident R102's physician order dated 9/5/24, indicated to transfer the resident with an assist of two persons. Review of Resident R102's Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 9/11/24, indicated diagnoses of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to update an individualized care plan to address the resident's specific nutritional concerns and preferences for one of four (Resident R82) records reviewed. Findings include: Review of facility policy Comprehensive Care Planning dated 7/1/24, indicated an interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis. Review of the admission record indicated that Resident R82 was admitted to the facility on [DATE]. Review of Resident R82's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/5/24, indicated the diagnoses cerebral palsy (a group of conditions that affect movement and posture caused by brain damage before birth), aspiration pneumonia (a lung infection caused by inhaling foreign substances like food, liquid or vomit), and gall bladder stones. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained and failed to maintain an accurate care plan for dialysis access site for one of one dialysis resident (Resident R39). Findings include: Review of the facility policy Hemodialysis Care Policy dated 7/1/24, indicated communication between the dialysis provider and facility staff will occur before and after each hemodialysis (a treatment for advanced kidney failure that filters wastes, salts, and fluid from your blood) treatment and as needed. Review of the facility policy Comprehensive Care Planning Policy, dated 7/1/24, indicated an interdisciplinary plan of care will be established for every resident and updated on an as needed basis. Review of the admission record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/29/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records and facility policy review, and staff interview, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services to correct the problem for one of five residents (Resident R2). Findings include: Interview with the facility's Administrator on 10/25/24, at 11:30 a.m. indicated they did not have a policy relating to treatment and services for mental and or psychosocial concerns. Review of the facility policy Managing Use of Unauthorized/Illegal Substances Policy dated 7/1/24, indicated this community does not permit the use of unprescribed medications, drugs, alcohol, or substances and/or those that are illegal by state or federal law. Review of the admission record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/15/24, indicated diagnoses of wound infection, depression,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon clinical record review, and staff interview, it was determined that the facility failed to ensure that any irregularities submitted in the medication regiment reviews (MRR) by pharmacy were acted upon for one out of five residents (Resident R12). Findings include: Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/7/24, indicated diagnoses heart failure condition in which the heart muscle is unable to pump enough blood to meet the body ' s needs for blood and oxygen), respiratory failure (results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels), and rhabdomyolysis (A breakdown of skeletal muscle due to direct or indirect muscle injury). Review of Resident R12's active physician order dated 2/28/24, indicated to administer 0.5ml of 2mg/ml lorazepam as needed for anxiety,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, and staff interview it was determined the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days for one of five residents (Resident R12), failed to identify a diagnosed specific condition for treatment, and failed to monitor the effectiveness or adverse consequences of psychotropic medication use for one of five residents (Resident R82) reviewed. Findings Include: Review of facility policy Psychoactive Medication Policy dated 7/1/24, indicated all residents receiving psychoactive medication[s] will have their behaviors, effectiveness of interventions (pharmacological and non-pharmacological) and potential for a gradual dose reduction of psychoactive medication monitored and documented. Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/7/24, indicated diagnoses heart failure condition in which the…

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

Based on review of facility policy, observations and staff interview it was determined that the facility failed to date opened medications and properly store medications in one of three medication carts observed Findings include: Review of facility policy Storage and Expiration Dating of Medications and Biologicals dated 7/1/24, indicated once any medication or biological package is opened, the facility staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened. Observation on 10/22/24, at 10:02 a.m. of the East Wing Front Hall medication cart indicated the following medications stored in the drawer without a date and time opened as required: -Symbicort (an inhaler used for easier breathing). -Albuterol (an inhaler used for easier breathing). -Fluticasone Propionate (steroid inhaler used for easier breathing) three separate inhalers not dated. Interview on 10/22/24, 10:05 a.m. Registered Nurse (RN) Employee E8 verified the multiple inhalant medications above were not dated when opened as required. Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure timely dental services for one of six residents reviewed for dental concerns (Resident 11). Findings include: Review of the facility Dental Services Policy dated 7/1/24, indicated the facility will assist residents in obtaining routine and 24-hour emergency dental care services to meet the needs of each resident. The Social Service personnel or designees will, if necessary or requested, assist the resident/ resident representative in making dental appointments and transportation arrangements to and from the dental services locations. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R11's MDS (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 6/18/24, indicated diagnoses depression and orthostatic hypotension (a form of low blood pressure that occurs when standing after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not.) for one of three residents (Resident R61). Findings include: Review of the admission record indicated Resident R61 was admitted to the facility on [DATE]. Review of Resident R61's Binding Arbitration Agreement indicated that the resident signed the document on 6/20/24. Review of Resident R61's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/26/24, indicated the diagnoses of cancer, Bipolar disorder (a serious mental illness characterized by extreme mood swings), and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of Resident Assessment Instrument (RAI) User's Manual, facility policy, resident clinical records, and staff interviews, it was determined the facility failed to obtain a diagnosis for hospice service, to ensure an accurate MDS assessment, and failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for two of four residents (Resident R12 and R41). Findings include: Review of facility policy Hospice Care Policy dated 7/1/24, indicated that this community provides hospice services through collaboration with a Medicare certified hospice agency when ordered by a resident's physician. Such services will be provided following these requirements: - The hospice services and those providing them will meet professional standards and be provided timely. - The facility will ensure that the resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for one of two residents with an enteral feeding tube. (Resident R68) Findings include: Review of the Centers for Disease Control (CDC) signage for Enhanced Barrier Precautions (EBP) indicated wear gloves and a gown for the following high contact resident care activities: Device care or use: central line, urinary catheter, feeding tube, and tracheostomy. Review of the facility policy Transmission-Based Precautions and Isolation Policy dated 7/1/24, indicated Enhanced Barrier Precautions (EBP) are indicated for high contact care activities for residents with chronic wounds and indwelling devices. Review of the clinical record indicated Resident R68 was admitted to the facility on [DATE]. Review of Resident R68's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/1/24, indicated the diagnoses of anemia (the blood doesn ' t have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that pneumococcal vaccinations were addressed in a timely fashion for two of five residents (Residents R68, and R114). Findings include: Review of the facility policy Resident Vaccination Policy dated 7/1/24, indicated residents and/or their responsible party will be asked about prior vaccinations at admission. Prior doses of influenza, pneumococcal, COVID-19, and other vaccines will be documented in the immunization portal in the electronic health record. Review of the admission record indicated Resident R68 admitted to the facility on [DATE]. Review of Resident R68's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/1/24, indicated the diagnoses of anemia (the blood doesn ' t have enough healthy red blood cells), high blood pressure, and renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids). Review of Resident R68's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, incident reports, resident and staff interviews it was determined that failed to report a resident-to-resident abuse altercation for two of three sampled residents (Resident R1 and Closed Resident Record CR2). Findings include: The facility Abuse, neglect, and exploitation policy dated 7/11/24, indicated that the facility will not tolerate abuse, neglect, mistreatment, and exploitation of residents. Facility staff must immediately report all such allegation to the Administrator. The Administrator will notify the applicable local and state agencies. Review of Resident R1's admission record indicated he was originally admitted on [DATE] and readmitted [DATE]. Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 4/9/24, indicated he had diagnoses that included dementia with behavioral disturbance (neuro-cognitive disorder impacting reasoning, judgment, and memory), anxiety disorder (a medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records and staff interviews, it was determined that the facility failed to monitor residents' weight for three of three residents reviewed. (Resident R1, Closed Record Resident CR1 and CR2) Findings include: Review of the facility policy Resident Weight Policy, dated 7/1/24, indicated weights will be obtained routinely in order to monitor nutritional health over time. Each resident's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified, or as ordered. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - periodic assessment of care needs) dated 7/14/24, indicated diagnoses of hip fracture (broken hip bone), rib fracture (broken rib bone), and s/p motor vehicle accident. Review of Resident R1's physician orders dated 7/8/24, indicated to obtain weight upon admission, then weekly for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for two of ten residents (Residents R1 and R2). Findings include: Review of the CFR §483.10(c)(7) indicated the resident has the right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate. Interview with the Nursing Home Administrator on 6/26/24, at 1:00 p.m. indicated the facility did not have a policy for self-administration of medications. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE] . Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/2/24, indicated the diagnoses of high blood pressure, anxiety (intense, excessive, and persistent worry and fear about everyday situations), and depression. Review of Resident R1's current physician orders on 6/26/24, at 9:04 a.m. failed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to update a care plan for one of 10 residents (Resident R3) to accurately reflect the current status of the resident. Findings include: Review of the facility policy Comprehensive Care Planning Policy dated 7/1/23, indicated an interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on as needed basis. Review of the admission record indicated Resident R3 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS- a periodic assessment of care needs) dated 4/9/24, indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), weakness, and dermatitis (skin inflammation). Section J1300 indicated tobacco use - Yes. Review of facility provided list of Smoking Residents updated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record, observation, and staff interview it was determined that the facility failed to have timely smoking assessments for two of ten residents (Residents R4, and R5). Findings include: Review of the facility policy Resident Smoking Policy dated 7/1/23, indicated residents are asked if they have a desire/intent to smoke while in the facility. Anyone answering yes is further assessed for smoking safety awareness and the need for reasonable physical or safety accommodations. The assessment is completed thereafter on readmission, quarterly and with any significant change in the resident's condition. Review of the admission record indicated Resident R4 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS- a periodic assessment of care needs) dated 4/4/24, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), heart failure (heart doesn't pump blood as well as it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observations and staff interviews it was determined that the facility failed to ensure that residents received complete neurological assessments after a fall and a complete set of vital signs every shift for 72 hours for one of three residents (Closed Record Resident CR1) and failed to make certain each resident received adequate supervision that resulted in two elopements (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of three residents (CR1). Findings include: Review of the facility's Incident and accident policy dated 7/1/23, indicated that an accident is any occurrence which is not consistent with routine care. The incident/accident will be recorded in the health record. Documentation regarding post-incident response and symptoms, and a complete set of vital signs will be completed every shift for 72 hours post-occurrence. Review of the facility's Neurological Checks dated 7/1/23, indicated upon…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, investigation documentation, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out neglect and/or abuse for one of three sampled residents (Resident R1). Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 8/3/23, indicated it is the facility policy to investigate all suspicions and incidents of neglect and injuries of unknown source. It was indicated written statements must be obtained from the resident, if possible, the accused, and each witness. It was indicated if there are no direct witnesses, then the interviews may be expanded. The facility policy Fall Prevention and Management Policy last reviewed 7/1/23, indicated all falls will be reviewed and investigated. Review of the clinical record indicated that Resident R1's was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/26/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record, facility policy, and staff interview, it was determined that the facility failed to develop a baseline care plan that included interventions needed to provide effective and person-centered care for one of three residents (Resident R1). Findings include: The facility policy Interim/Baseline Care Planning Policy last reviewed 7/1/23, indicated a baseline care plan to meet the resident's immediate needs shall be developed within forty-eight hours of the resident's admission. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE], with the diagnoses of diagnoses fall, dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), and COVID (a contagious respiratory virus). Review of Resident R1's John Hopkins Fall Risk dated 12/19/23, indicated the resident was a high fall risk. Review of Resident R1's clinical record from 12/19/23, through 12/21/23, failed to include a baseline care plan that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to provide needed care and services to prevent falls, provide an ongoing assessment post fall, and follow physician orders for one of three residents (Resident R1). Findings include: The facility policy Fall Prevention and Management Policy last reviewed 7/1/23, indicated residents will be assessed for fall risks on admission, quarterly, after any fall, and as needed. It was indicated if risks are identified, preventive measures will be put in place and care planned. All falls will be reviewed and investigated. The facility policy Interim/Baseline Care Planning Policy last reviewed 7/1/23, indicated a baseline care plan to meet the resident's immediate needs shall be developed within forty-eight hours of the resident's admission. Review of the clinical record indicated that Resident R1's was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment…

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, observation, and staff interviews, it was determined that the facility failed to properly store medical supplies and biologicals in one of two medication rooms (East Medication Room). Review of the facility policy Storage and Expiration of Medications, Biologicals, Syringes, and Needles dated 7/1/23, indicated the facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. The facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medications are biologicals are stored. Findings include: During an observation of the East Medication Room on 11/7/23, at 10:01 a.m. the following was observed in the medication refrigerator: - Three single serve packages of butter, stored in a Tylenol box. During an observation of the East Medication Room on 11/7/23, at 10:04 a.m. the following was observed under the sink: - A silver tray - A can of soup - A sharps storage container During an…

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

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to provide a safe and sanitary environment to help prevent the potential for cross contamination for one of two medication rooms (East Medication Room). Findings include: Review of the facility policy Storage and Expiration of Medications, Biologicals, Syringes, and Needles dated 7/1/23, indicated the facility should ensure that resident medication and biological storage areas are locked and do not contain non-medical biological items. Review of the facility policy Infection Prevention and Control Program Policy dated 7/1/23, indicated the facility is to maintain a facility-wide program designed to prevent, identify, control and reduce the risk of acquiring and transmitting infection among employees, volunteers, and contracted health care workers. During an observation of the East Medication Room on 11/7/23, at 10:06 a.m. personal staff jackets were hanging on a coat rack that had been adhered to the wall on the right side of wall immediately upon entrance of medication…

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

Based on observations and staff interviews it was determined that the facility failed to have required postings for the Medicaid fraud control unit for the facility. Findings include: Observations on the nursing care unit bulletin board failed to include information for the Medicaid fraud control unit throughout the survey from 11/6/23 through 11/9/23. During observations on 11/9/23, at 12:29 p.m. with Nursing Home Administrator confirmed that the facility failed to post information about the Medicaid fraud control unit. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18e Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate an incident for one of three residents reviewed (Resident R157). Findings include: A review of the facility's Abuse, Neglect, and Exploitation dated 7/1/23, indicated It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown source. Facility staff must immediately report all such allegations to the Administrator/abuse Coordinator. Review of the clinical record indicated Resident R157 was admitted to the facility on [DATE]. Resident R157 admit sheet indicated they were admitted , with diagnosis of Fibromyalgia (chronic disorder characterized by widespread pain and other symptoms such as fatigue and muscle stiffness), Type 2 Diabetes (problem in the way the body regulates and uses sugar as fuel), 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.