Cedar Hill Healthcare And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review and staff interviews, it was determined to 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 one residents (Resident R73). Findings: Review of Resident R73's record indicated the resident was admitted on [DATE]. Diagnoses included post-traumatic stress disorder (PTSD - a psychiatric disorder that may occur in persons that have witnessed a traumatic event causing intense, disturbing thoughts and feelings related to the experience), dysphagia (difficulty or impairment in swallowing) and anxiety. Review of physician orders dated 8/13/25, included buspirone (medication used to treat anxiety) and fluoxetine (medication used to treat anxiety). Review of Resident R73's assessments did not include a Trauma Informed Care Evaluation (a data collection tool that gathers information on traumatic events and aids in identifying and addressing the resident's needs). Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, the facility's tray assembly tickets, observation, and resident and staff interviews, it was determined that the facility failed to follow their tray assembly tickets for preferences for two of five residents (Resident R11 and R124). Findings include: Review of the facility policy Dining and Food Preferences dated 4/2/25, indicated individual dining, food, and beverage preferences are identified for all residents. The individual tray assembly ticket will identify all food items appropriate for the resident based on diet order, allergies and intolerances, and preferences. Review of the admission record indicated Resident R11 was admitted to the facility on [DATE]. Review of the Resident R11's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/10/25, indicated the diagnoses of anemia (low iron in the blood) high blood pressure and diabetes (high sugar in the blood). Review of Resident R11’s physician orders dated 5/12/25, indicated low potassium diet,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of resident council meeting minutes, review of grievance logs, observations, staff and resident interviews it was determined that the facility failed to accommodate the call bell needs for four of nine residents (Resident R2, R3, R4 and R7) Findings include: Review of facility policy Call Lights last reviewed 4/2/25, indicated a call light system is used by this facility to respond to the resident request and needs. Answer the resident's call as soon as possible. Review of the facility policy Call Light Response last reviewed 4/2/25, indicated staff will respond to the call light and the residents request and needs in a timely manner. Review of the facility policy Flow of Care last reviewed 4/2/25, indicated care will be provided to residents, as needed 24 hours a day to attain and maintain the highest level of functioning. The flow of care is to be implemented on a continuous basis to promote quality of life with the resident. Call light within reach for all residents…

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

Based on review of facility policy, resident clinical records, observations, and staff interviews, it was determined that the facility failed to use Personal Protective Equipment (PPE) appropriately, which created the potential for the cross-contamination and the spread of diseases and infections in two out of 18 droplet precautions (infection control measures designed to prevent the spread of infectious diseases that are transmitted through respiratory droplets) rooms. (Covid and Exposed Unit). Findings include: Review of facility policy Isolation Procedure: Resident placement in Transmission-Based Precautions dated 4/17/24, indicated transmission-based precautions (including droplet) will be implemented when indicated by suspicion or presence of infectious disease. Initiate precautions as indicated. Review of facility policy Personal Protective Equipment dated 4/17/24, indicated personal protective equipment (PPE) is available at all times. PPE includes gowns, gloves, masks, eyewear. Review of facility policy Coronavirus (Covid-19) policy dated 4/17/24, indicated 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.

Based on review of facility policy, observations, and staff interview it was determined that the facility failed to provide privacy and confidentiality of resident healthcare information for twelve of thirty-seven residents (Residents R3, R28, R33, R57, R76, R81, R94, R117, R122, R123, R131 and R435). Findings include: The facility policy Health Insurance Portability and Accounting Act of 1996 (HIPPA) dated 4/17/24, indicated this facility will keep information regarding a resident ' s health private and confidential. The facility policy Resident rights dated 4/17/24, indicates this facility will protect and promote the rights of each resident, including but not inclusive to privacy and confidentiality. The facility policy Coronavirus (Covid-19) dated 4/17/24, indicated this guidance is to provide the facility an overview of key actions required to reduce risk and prevent the potential spread of infections to patients and staff. Procedure includes but not inclusive to placing appropriate signage outside of room to identify that precautions are needed. During an observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations and staff interview it was determined that the facility failed to the failed to ensure medications were not left unattended at the bedside for three of three of seven residents (Residents R36, R50 and R98). Findings include: Review of the facility Medication Administration policy dated 4/17/24, indicated medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so to comply with federal laws governing medication administration and in order to ensure safe, accurate, and timely administration of medications. In order for residents to self-administer medications, an attending physician must authorize to do so in accordance with procedures for self-administration of medications. Review of the facility Storage of Medications policy dated 4/17/24, indicated medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain call bells were in reach for two of seven residents as required (Resident R30 and R108). Findings include: The facility policy Call Lights dated 4/17/24, indicated when a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Review of Resident R30's clinical record indicated admission to the facility on 3/13/24. Review of Resident R30's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/19/23, indicated diagnoses of hypertension (high blood pressure) hyperlipidemia (high fats in the blood) and depression. During an interview and observation on 9/16/24, at 10:05 a.m. Resident R30's was sitting in her wheelchair, her call light button was wrapped on enabler/side rail assist bar on the other side of bed. When Resident R30 was asked what she would do if she needed help, she stated I don't know, I can't reach have my…

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

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to assure physician orders, residents' Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments), was available for one of four residents (Residents R336). Findings include: The facility Advanced Directives policy dated 4/17/24, indicated that this policy shall establish guidelines for medical treatment decision-making that both recognize and respect the residents right of self-determination. Review of Resident R336's clinical record indicate an admission date of 9/13/24, with diagnoses including diabetes (high sugar in the blood), hypertension (high blood pressure), and hyperlipidemia (high fat in the blood), Review of Resident R336 clinical record 9/18/24, at 12:30 p.m. failed to reveal a POLST (Physician Orders for Life Sustaining Treatment) or a physician order for code status. During an interview on 09/18/24, at 12:37 p.m. Licensed Practical Nurse Employee E3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical records, and staff interviews, 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 two of two residents (Resident R41, and R107). Findings Include: A review of the facility policy Documentation of Discharges or Deaths last reviewed 4/17/24, indicated all discharges will be sent to the Office Ombudsman's office at the end of the month. Review of Resident R41's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of hypertensive heart disease without heart failure (long-term condition that develops over many years in people who have high blood pressure), dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss…

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

Based on review of clinical records and staff interview it was determined that the facility failed to provide care and services according to accepted standards of clinical practice in the identification of a resident's diagnosis of schizoaffective disorder for one of five residents (Resident R45). Findings include: Review of the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth Edition, Schizoaffective Disorder, Diagnostic Criteria included, but is not limited to: A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion-A of schizophrenia: --Two (or more) of the following, each present for a significant portion of time during a one-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): --1. Delusions. --2. Hallucinations. --3. Disorganized speech (e.g., frequent derailment or incoherence). --4. Grossly disorganized or catatonic behavior. --5. Negative symptoms (i.e., diminished emotional expression or avolition).…

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 interviews, it was determined that the facility failed to provide adequate supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one out of three sampled residents (Closed Resident Record CR132). Findings include: The facility Resident elopement policy dated 4/17/24, indicated that elopement is defined as a resident leaving the physical structure of the facility without the knowledge of facility staff. Review of Closed Resident Record CR132's admission record indicated he was admitted on [DATE]. Review of Closed Resident Record CR132's initial nurse assessment dated [DATE], indicated he was admitted with diagnosed that include chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), hyperlipidemia (elevated lipid levels within the blood), and generalized muscle weakness.…

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 interview, the facility failed to have physician order specifications relating to size of indwelling catheter for one of three residents (Residents R103). Findings include: Review of facility policy Indwelling Foley Catheter, Appropriate Use Protocol dated 4/17/24, indicated indwelling catheters will be only changed if needed due to leakage or becoming dislodged or clogged. Review of the facility policy Medication and Treatment Orders dated 4/17/24, indicated treatment orders will contain what is to be done, frequency, and duration of treatment. Review of admission record indicated Resident R103 was admitted to the facility on [DATE], with diagnoses of high blood pressure, kidney insufficiency, and depression. Review of Resident R103's care plan dated 12/12/23, indicated the resident had a foley catheter (a tube inserted in the bladder to drain urine.) Review of Resident R103's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/16/24,…

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 observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain physician's orders, conduct ongoing accurate assessments and failed to obtain a consent to ensure that enabler/side rail assist bars were used to meet residents' needs and the risks associated with enabler bar/side rail assist bar usage for two of three residents (R30 and R75). Findings include: Review of facility policy Proper Use of Enabler Bars dated 4/17/24, indicated side rails may be used as resident mobility aids and the use of side rails as restraints, will not be used unless necessary to treat a medical symptom. Guidelines include but are not inclusive to: -An assessment will be made to determine the resident's symptoms or reason for using side rails. -Informed consent for the use of less restrictive devices will be obtained from the resident or legal representative per facility protocol. Review of Resident R30's clinical record indicated admission to the…

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

Based on review of facility policy, Nursing staff personnel records, nurse training documentation and staff interview, it was determined that the facility failed to ensure that nursing staff received annual in-service education for one out of six nursing personnel (Registered Nurse Employee E5). Findings include: The facility In-service training policy dated 4/17/24, indicated that the facility will provide in-service training for all personnel. All mandatory in-service requirements must be completed annually as a condition of continued employment. Training topics include residents rights, abuse, neglect and exploitation, behavioral health, infection control, compliance and ethics, effective communication, and dementia management. Review of Registered Nurse (RN) Employee E5's personnel record indicated she was hired to the facility on 2/20/97. Review of Registered Nurse (RN) Employee E5's personnel record did not include annual in-services on resident rights, person centered care, communication, basic nursing skills, basic restorative services, skin and wound care, medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician for one of of three residents (Resident R385). Findings include: A review of facility policy Medication administration dated 4/17/2024, indicated that medications are administered, as prescribed, in accordance with good nursing principles and practices and only persons legally authorized to do so to comply with Federal Laws governing Medication Administration and in order to ensure the safe, accurate and timely administration of medications. A review of Resident R385 admission record indicated that she was admitted to the facility on [DATE]. A review of Resident R385's Minimum Data Set assessment (MDS - a periodic assessment of care needs) dated 8/2/24, indicated she had with diagnoses that included diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), chronic kidney…

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

Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to properly disinfect a respiratory equipment spacer (spacer- a plastic tube with a mouthpiece on one end, allows the person more time to inhale allowing medication to enter the lungs more efficiently) prior to placing in medication cart for one of three residents (Resident R136) and failed to prevent cross contamination during a dressing change for one of three residents (Resident R90). Findings Include: Review of the Aero Chamber Z STAT manual cleaning instructions for mask and mouthpiece chambers indicate: -Soak the parts for 15 minutes in a mild solution of liquid dish detergent and lukewarm clean water. -Agitate gently. -Rinse parts in clean water. -Dishwasher safe, avoid heated dry over 158*, parts on top rack only. -Do not boil or sterilize. -Shake out excess water from the parts and allow to air dry in a vertical position. -Ensure parts are dry before reassembly. Review of facility policy Oral Inhalation Administration) reviewed 4/17/24, indicated 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 facility policy, resident council meeting minutes and resident and staff interviews, it was determined that the facility failed to provide evidence that Resident Council concerns were assigned to the appropriate department, facility responses to Resident Council concerns, and how the facility resolved the repetitive Resident Council concerns for three of three months (January, February, and March 2024). Findings include: The facility indicated they do not have a Resident Council policy. Review of the facility policy Grievances dated 8/16/23, indicated the resident has the right to voice grievances with respect to treatment which has been furnished as well as that which has not been furnished. The facility actively seeks a resolution and keeps the resident appropriately apprised of its progress toward resolution. Review of Resident Council meeting minutes for the meeting on 1/15/24, indicated the following concerns: call lights not being answered on evening and night shifts, unable to find Nurse Aides (NA), they are always on their phones, have attitudes, not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and investigative documents, it was determined that the facility failed to provide quality of care with an unlicensed employee providing medications to six residents. This was identified as a past non-compliance for six of six residents (Resident R1, R2 R3, R4, R5 and R6). Findings include: Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Review of the job description for NA (Nursing Assistant) indicated job functions to include: duties and responsibilities, administrative, committee, personnel, and specific job function, staff development, competency, safety, equipment & safety functions, financial responsibilities, customer service and resident rights. Giving…

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 policy review, observations, and staff interview, it was determined that the facility failed to maintain a clean, comfortable, homelike environment in five out of 12 sampled resident rooms (Residents R2, R5, R6, R7, and Resident R8). Findings include: The facility Resident environment policy stated 8/16/23, indicated that the facility will provide an environment that is safe, clean, comfortable and homelike During a tour with Housekeeping Supervisor Employee E2 on 2/13/24, starting at 11:24 a.m. the following was observed: At 11:27 a.m. Residents R5's room was observed with a large crack in the wall under her window. The crack had a white-powered substance falling out of wall. At 11:29 a.m. Residents R6's room was observed with brown spots on the floor in front of the bed. At 11:30 a.m. Residents R7's room was observed with a large black spot on the privacy curtain. At 11:31 a.m. Residents R2's room was observed with large gauges on the wall behind her oxygen concentrator. At 11:36 a.m. Residents R8's room was observed brown tile in front of his bathroom. The tile was…

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

Based on review of facility documentation, observations, resident interview and staff interviews it was determined that the facility failed to consistently maintain functional telephone services and uphold residents' ability to communicate with individuals for two out of four observed resident phones (Resident R1 and Resident R2). Findings include: The facility Telephone policy dated 8/16/23, indicated that the resident has the right to have reasonable access to the use of a telephone where calls can be made without being overheard. It is the policy of this facility to provide every resident with an opportunity to have access to a telephone for private conversations with loved ones and friends. During an interview on 2/13/24, at 9:32 a.m. Maintenance Supervisor Employee E1 stated when asked any complaints about the phone functioning: yes, its all over the building. It is an issue. Been an issue for 2-3 months. Before, we had analogue phone lines. Now, phone call goes through the computer and all the phone extensions changed. During observations with Maintenance Supervisor Employee…

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

Based on observation and staff interview, it was determined that the facility failed to secure confidential medical information on staff computers for two out of seven medication carts (300 hall/Sub-acute and 100 hall/South). Findings include: The facility Health insurance portability and accountability act. last reviewed on 8/16/23, indicated that the facility will keep information regarding a resident's health private and confidential. This includes information on paper, fax or computer. During observations on 2/13/24, at 9:11 a.m. the 300 hall/subacute medication cart was observed with a staff computer on it. Observations found Resident R3 confidential medical information on the screen and fully exposed. No staff were observed near the medication cart During observations on 2/13/24, at 9:16 a.m. the 100 hall/South medication cart was observed with a staff computer on it. Observations found Resident R4 confidential medical information on the screen and fully exposed. No staff were observed near the medication cart During an interview on 2/13/24, at 10:46 a.m. the Director 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 vendor invoices, facility financial documents, as well as interviews with vendors and staff, it was determined that facility failed to pay bills in a timely manner which created a potential for an interruption of supplies and services. Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), dated 7/1/23, indicated that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are jeopardized. During an interview on 12/27/23, at 10:16 a.m., Medical Director Vendor V1 stated that he has not been paid for services provided as the facility Medical Director since July of 2023. Review of invoices dated 8/31/23, 9/30/23, 10/31/23, and 11/30/23, reveals charges related to services provided as the facility Medical Director of $3000.00 per month, totaling a past due balance of $12,000. Review of an electronic…

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 vendor invoices, facility financial documents, as well as interviews with vendors and staff, it was determined that the governing body failed to implement policies regarding the management of the operation of the facility by failing to respond to vendor invoices and failing to respond to facility requests for payment of outstanding bills. Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), dated 7/1/23, indicated that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are jeopardized. During an interview on 12/27/23, at 10:16 a.m., Medical Director Vendor V1stated that he has not been paid for services provided as the facility Medical Director since July of 2023. Review of invoices dated 8/31/23, 9/30/23, 10/31/23, and 11/30/23, reveals charges related to services provided as 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.

Based on facility document review, observation, and staff interview, it was determined that the facilityfailed to provide an ongoing activity program to meet the needs of the residents by failing to respond to facility requests for supplies and by failing to respond vendor invoices which caused entertainment activities to be canceled and refusals of entertainers to return to the facility. Findings include: Review of an Activity Entertainer Invoice dated 6/4/23, revealed Entertainment Vendor V9 provided vocal entertainment on 6/2/23, with a charge of $125.00. This invoice included an approved purchase order number. On 12/31/23, at 8:59 a.m. the Activities Director Employee E5 confirmed that this vendor has not been paid. [Vendor V9] has been coming to our building for years with the residents. He told me he will never come back because they never paid him. Review of an Activity Entertainer Invoice dated 7/5/23, revealed Entertainment Vendor V10 provided musical entertainment on 7/5/23, with a charge of $150.00. This invoice included an approved purchase order number. On 12/27/23, at…

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

Based on review of infection control documentation and staff interview, it was determined that the facility failed to have one or more individuals serving as the Infection Preventionist for seven of twelve months (November 2022, December 2022, January 2023, June 2023, July 2023, August 2023, and September 2023). Findings include: Review of the Pennsylvania Department of Health notice PAHAN #626, dated 2/15/22, PAHAN #663, dated 10/4/22, PAHAN #694, dated 5/11/23, indicated long-term care facilities should Assign one or more individuals with training in IPC (infection preventions and control) to provide on-site management of the IPC program. This should be a full-time role for at least one person in facilities that have more than 100 residents. During an interview on 10/10/23, at 9:38 a.m. Regional Clinical Consultant Employee E5 stated, the current Infection Preventionist is in the training process. Myself and another Regional Clinical Consultant have been overseeing it but we do not work full time at this building. During an interview on 10/11/23, at 11:30 a.m. the Infection…

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

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for 16 of 19 new admissions in the past 30 days. Findings include: A review of facility policy MDS/RAI/Care Planning last reviewed 8/16/23, indicated to ensure coordination and implementation of each resident's plan of care, individualized for each residents strengths, problems, and needs. A review of Title 42 Code of Federal Regulations (CFR) §483.21(a) - Baseline Care Plans states that the facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care and the baseline care plan must be developed within 48 hours of a resident's admission. A review of the facility's new admissions within the past 30 days 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.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly and securely store medications in two out of four medications carts (South and Subacute). Findings include: A review of facility policy Storage of Medications last reviewed 8/16/23, indicated that medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. Medications are stored in the containers in which they are received. Drug containers having soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels are relabeled before storing. Each resident is assigned a cubicle or drawer to prevent the possibility of a drug for one resident being given to another. During an observation on 10/11/23, at 9:28 a.m. of the South medication cart indicated the following medications stored in one compartment without individual packaging or separation from other residents medications: - Resident R60's Basaglar pen (prefilled pen to inject long acting insulin under the skin) and NovoLog…

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

Based on review of facility documentation, resident and staff interviews, and review of facility policy the facility failed to make certain that all residents had the access/ability to file a grievance, that the facility documented a residents grievance, and that the facility had a policy and procedure that met federal guidelines for one of six residents (Resident R71). Findings include: Review of facility policy Concern Procedure- Resident/Family dated 8/16/23, indicated : When a staff member becomes aware of a resident or family concern, a Resident/Family Concern Form will be completed. The original will be forwarded to the Social Services Director. Copies of the concern will be provided to the appropriate departments for resolution. Responses and/or resolutions to the concern will be returned from those departments to the Social Services Director. All responses to Resident/family concern forms will be forwarded to the Social Service Director within five (5) days of receipt of the initial concern. Review of the facility policy Grievances dated 8/16/23, indicated This facility will…

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 ensure that a resident was free from neglect by not providing a two-person transfer per physician's order for one of six sampled residents (Resident R13). Findings include: Review of facility policy Abuse Protection last reviewed 8/16/23, indicated that residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate, and appropriate services, treatment of care, including but not limited to nutrition, medication, therapies, and activities of daily living. The absence of reasonable accommodations of individual needs and preferences…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and facility investigative documents, and staff interviews, it was determined that the facility failed to ensure that residents were free from misappropriation (the act of stealing something that you have been trusted to care of and using it for yourself) of medications for one of five residents reviewed (Residents R216). Findings include: Review of the facility policy Abuse Reporting and Investigation dated 8/16/23, indicated types of abuse include verbal abuse, sexual abuse, physical abuse, involuntary seclusion, mental abuse, neglect, and misappropriation of resident property. Review of admission record indicated Resident R216 was admitted to the facility on [DATE]. Review of Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/22/22, indicated the diagnoses of anemia (the blood doesn ' t have enough healthy red blood cells), high blood pressure, and diabetes (too much sugar in the blood). Review of the Brief Interview for Mental Status (BIMS, a screening…

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 documentations, 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 six sampled residents (Resident R13). Findings include: Review of facility policy Abuse Reporting and Investigation last reviewed 8/16/23, indicated that the facility will thoroughly investigate all reports of suspected or alleged abuse, neglect, or exploitation. Review of facility policy Abuse Protection last reviewed 8/16/23, indicated neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate, and appropriate services, treatment of care, including but not limited to nutrition, medication, therapies, and activities of daily living. The absence of reasonable accommodations of individual…

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 and clinical records and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for three of 13 residents (Resident R28, R51, and R85). 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 2018, and updated October 2019, indicated that Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, and that it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood. Further review of the RAI indicated under Coding Tips rules for stopping the BIMS before it is complete: 1. All responses up to this point have been nonsensical (making no sense), 2. there has been no verbal or written response to any of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interview it was determined that the facility failed to implement comprehensive care plans for one of six clinical records reviewed (Resident R98). Findings include: Review of facility policy MDS/RAI/Care Planning, dated 8/16/23, indicated that the facility is to Develop a written plan of care individualized for each resident, which identifies through an assessment process, his/her strengths, problems, needs. Resident R98 was admitted to the facility on [DATE]. Review of Resident R98 MDS (minimum data set - a brief periodic assessment of resident needs) dated 8/29/23, indicated that Resident R98 had the diagnosis of sepsis ( when an infection you already have triggers a chain reaction throughout your body) , UTI (infection in any part of the urinary system), and bacteremia (presence of bacteria in the bloodstream). Review of Resident R98 clinical record physician orders indicated that resident had a foley catheter, IV Medications, PICC Line, and a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interview the facility failed to update and revise care plans for one of six residents reviewed (R98). Findings include: Resident R98 was admitted to the facility on [DATE]. Review of Resident R98 MDS (minimum data set - a brief periodic assessment of resident needs) dated 8/29/23, indicated that Resident R98 had the diagnosis of sepsis ( when an infection you already have triggers a chain reaction throughout your body) , UTI (infection in any part of the urinary system), and bacteremia (presence of bacteria in the bloodstream). During an interview on 10/ 10/23, at 12:28 p.m. Resident R98 indicated that their teeth had been removed and the they received dentures. Review of Resident R98 clinical record showed a care plan for dental care. Additional review of the clinical record care plans failed to include information on dentures or on denture care. During an interview on 10/13/23, at 10:01 a.m. Employee E1 RNAC (Registered Nurse Assessment Coordinator) confirmed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview it was determined that the facility failed to assess, stage and size a residents wound at admit for one of four Residents reviewed (Resident R105). Findings include: Review of the clinical record indicated Resident R105 was admitted to the facility on [DATE], with the following diagnosis of UTI ( urinary tract infection - an infection in any part of the urinary system), and unspecified intellectual disabilities (deficits of adaptive functioning that result in failure to meet developmental and sociocultural standards). Review of the MDS (minimum data set - a brief periodic assessment of the resident needs) dated 9/19/23, indicated the diagnosis remained current. Review of the clinical record progress notes dated 6/23/23, indicated Resident R105 has a DTI on buttock. Further review of the clinical record failed to show any assessment, staging of wound until 7/23. During an interview on 10/13/23, at 1:42 p.m. Director of Nursing confirmed that the facility…

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