Corry Manor

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to review and/or revise resident care plans to reflect resident's current condition and failed to ensure that resident care plan meetings were held timely for two of 25 residents reviewed (Residents R22 and R56). Findings include: Review of facility policy entitled “Care Plan Policy” dated 12/4/24, revealed that the care plans are periodically reviewed and revised by a team of qualified persons after each assessment. The policy further indicated that the Resident will have the opportunity to discuss their goals for care including their preferences for advanced care planning with the interdisciplinary team. Resident R22's clinical record revealed an admission date of 6/21/19, with diagnoses that included obstructive and reflex uropathy (urinary tract disorder that occurs when urine flow is obstructed), benign hyperplasia prostatic (an enlarged gland below the bladder that causes difficulty urinating) with lower urinary tract symptoms, weakness and dementia (a…

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

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of two residents reviewed for respiratory services (Resident R88). Findings include: Review of facility policy entitled Oxygen Concentrators dated 12/4/24, indicated external filters are to be cleaned weekly. Prefilled bubble humidifier bottles. need to be changed weekly and as needed. Review of Resident R88's clinical record revealed an admission date of 5/7/25, with diagnoses that included respiratory failure (a condition where your lungs don't exchange air properly), Chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and hypertension (high blood pressure). Review of Resident R88's physician's orders revealed orders for oxygen (O2) two liters per minute PRN (as needed) via nasal cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen) dated 8/7/25, and oxygen maintenance change O2 tubing and supply bag weekly, wipe down…

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 appropriately discard outdated medications for one of two medication carts reviewed and one of one medication rooms reviewed (facility medication room and A wing medication cart). Findings include: Review of facility policy entitled Medication Storage dated 12/4/24, indicated Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations. and Outdated, contaminated, or deteriorated medications. are immediately removed from stock. Review of manufacturer's guidelines revealed that an open pen of Lantus Insulin must be used within 28 days after opening or be discarded, even if the pen still contains insulin. Review of manufacturer's guidelines revealed that an open pen of Aspart Insulin must be used within 28 days after opening or be discarded. Review of manufacturer's guidelines revealed that an open vial of Tubersol should be discarded within 30 days after opening. Observation of drug storage on 9/8/25, at 2:35 p.m. 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 Hospice contract, facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain that Hospice documentation was maintained in the clinical record for one of 25 residents reviewed (Resident R74).Findings include: Review of the facility Hospice contract indicated that coordination of care between the nursing facility staff and the Hospice Interdisciplinary Team. It further indicated that Hospice will maintain a medical record of hospice services provided and that the record will be incorporated into the nursing facility medical record. Hospice personnel will chart the services in this record. Review of facility policy Hospice Policy, dated 12/04/24, indicated that the facility shall take direction from the Hospice agency regarding implementation of the coordinated plan of care related to the resident's terminal illness. The policy also indicated that the attending physician will make an order for Hospice services. Review of Resident R74's…

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

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to notify the resident's emergency contact/representative regarding a transfer to the emergency room and a change in condition in a timely manner for one of two residents reviewed (Resident R1). Findings include: Review of the facility policy entitled Notification of Changes dated 12/4/24, revealed that The Manor must inform the resident immediately, the attending physician, and the resident's representative or interested family member when there is a significant change in the resident's physical, mental, or psychosocial status. Review of Resident R1's clinical record revealed an admission date of 1/23/25, with diagnoses that included hypertension (high blood-pressure), muscle weakness, and a presence of an aortocoronary bypass graft (a surgical procedure that improves blood flow in the heart by treating narrowed or blocked arteries). Review of Resident R1's clinical record revealed a progress note dated 2/2/25, at 2:15 a.m. indicating the resident was…

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

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 develop comprehensive person-centered care plans for each resident that included measurable objectives and timetables to meet a resident's needs for one of 25 residents reviewed (Resident R95) and for one of five residents reviewed with an indwelling catheter (tube inserted into the bladder to drain urine) (Closed Record Resident CR12). Findings include: A facility policy entitled, Comprehensive Care Plan, dated 12/26/23, indicated the facility will develop a comprehensive person centered care plan for each resident that includes measurable objective and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, and include: services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; be developed within seven days after the completion of…

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

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for two of 25 residents reviewed (Residents R51 and R91). Findings include: Review of a facility policy entitled Comprehensive Care Plan dated 12/26/23, indicated that Periodically reviewed and revised by a team of qualified persons after each assessment. Resident R51's clinical record revealed an admission date of 7/4/24, with diagnoses that included Hyperlipidemia (high cholesterol), Hypertension (high blood pressure), and Gastro Esophageal Reflux Disease (a condition when stomach acid repeatedly flows back up into your throat). Review of Resident R51's Plans of Care revealed a plan of care for risk for skin breakdown with a target date (a date that the care plan is to be updated by) of 8/07/24. During an interview with the Registered Nurse Assessment Coordinator (RNAC) on 11/06/24, at 1:10 p.m. he/she confirmed the care plan for Resident R51 was not reviewed/revised 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 clinical and hospital records, a review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), and staff interviews, it was determined that the facility failed to provide needed care or services resulting in an actual or potential decline in one or more residents' physical, mental, and/or psychosocial well-being for one (Closed Record Resident (CR12) of five residents with an indwelling catheter (tube inserted into the bladder to drain urine) and reposition two of 25 residents reviewed (Residents R15 and R38). Findings include: A facility policy, entitled Quality of Care Policy/Activities of Daily Living, dated 12/26/23, revealed each resident will receive and the Manor will provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. A resident's abilities…

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 ensure a safe environment related to smoking for three of eight residents reviewed who smoke at the facility (Residents R11, R14, and R104). Findings include: A facility policy entitled, Smoking Policy, dated 12/26/23, revealed for those Manors that permit smoking the purpose is to provide maximum safety to all resident at all times. It is the intent of the Manor to provide an environment to all those residents, who wish to smoke, the opportunity to do so in a safe environment, with optimal safety to themselves, other residents, volunteers, visitors, and staff members. Residents will be informed of the written smoking policy prior to admission. Smoking will be allowed in designated areas only. Residents must be accompanied by staff, family, or properly trained volunteers while smoking. Smoking materials will be kept in a designated area accessible only by staff. This includes the safekeeping of electronic cigarettes. Staff members are strictly prohibited from…

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

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that a resident's physician thoroughly documented a review of the resident's current condition, progress, and problems in maintaining or improving their physical, mental and psychosocial well-being and decisions about the continued appropriateness of the resident's current medical regimen for one (Closed Record Resident CR12) of 25 residents reviewed. Findings include: A facility policy entitled, Physician Services dated 12/22/23, indicated: 1. The resident's total plan of care (including medications and treatments) must be reviewed with each scheduled visit. 2. A progress note must be written, signed, and dated for each physician visit and that each progress note must contain. - An evaluation of the resident's condition, treatment, and a review of the continued appropriateness of the resident's current medical regimen. - Continuity of care in maintaining or improving a resident's condition and current medical regimen. - The resident's progress or…

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

Based on review of facility policies, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of one walk-in coolers, failed to label food brought into the facility with the resident's name and date it was opened in one of one pantry and failed to utilize hair nets to prevent contamination in the kitchen. Findings include: Review of facility policy entitled Storage of Perishable Foods dated 12/26/23, revealed Many perishable food items may be served until the manufacturer's use by date. Review of facility policy entitled Food Brought by Family/Visitors dated 12/26/23, revealed All foods requiring refrigeration must be dated and labeled with the resident's name . Perishable items may be stored for no greater than 3 days. Review of policy entitled Dress Code dated 12/26/23, revealed Purpose: To present a well-groomed appearance . to provide a standard of sanitation in dress. b. Hair net, beard if facial hair present. Observations of the kitchen on 11/04/24, at 10:40 a.m. revealed…

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

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 ensure the physician orders and Pennsylvania Orders for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for one of 25 residents reviewed (Resident R80). Findings include: Review of facility policy entitled Advance Directives Policy - PA dated [DATE], indicated General Policies All decisions to withhold or withdraw treatment or services . are subject to the following policies: 2. Documentation b. The physician's order should also be noted on the resident's plan of care and on the inside of the resident's clinical record. Review of Resident R80's clinical record revealed an admission date of [DATE], with diagnoses that included Diabetes (a health condition that caused by the body's inability to produce enough insulin), Dementia (a disease that affects short term memory and the ability 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 observation, review of facility and clinical records, and staff and resident interviews it was determined that the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior for one resident (Resident R36) and maintain sanitary resident specific equipment for one resident (Resident R4) of 25 residents reviewed. Findings include: No facility policy provided. Resident R36's clinical record revealed an admission date of 12/20/23, with diagnoses that included end-stage renal disease, dependence on renal dialysis, right below the knee amputation, and peritonitis (life-threatening condition that occurs when the peritoneum, the tissue that lines the abdomen, becomes inflamed or infected), and a physician's order dated 10/30/24, to set up, prime, and run cycler with two-six liter yellow bags Sunday, Tuesday, Wednesday, Friday, and Saturday. Observation on 11/04/24, at 3:40 p.m. of Resident R36's room revealed one full dialysate (fluid used in dialysis to exchange solutes with the blood and remove waste products from 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 clinical records, observations, and staff interview, it was determined that the facility failed to provide appropriate urinary catheter (tubing inserted into the bladder to drain urine into a bag) care for one of two residents reviewed for catheters (Resident R44). Findings include: Review of Resident R44's clinical record revealed an admission date of 3/12/23, with diagnoses that included Obstructive and Reflux Uropathy (disorder where urine cannot flow through the urinary tract due to an obstruction and backs up into the kidneys), Retention of Urine (a condition where the bladder doesn't empty completely when urinating), Urinary Tract Infection (an infection in any part of the urinary tract), and Overactive Bladder (a bladder control problem leading to a sudden urge to urinate). Review of Resident R44's clinical record revealed a physician's order dated 9/11/23, for an indwelling catheter. Observations on 11/05/24, at 11:30 a.m. revealed Resident R44 lying in bed with his/her urinary drainage bag lying on the floor with the valve (a device that allows you to…

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

Based on review of clinical records, and staff interviews, it was determined that the facility failed to provide a clinical rationale and duration for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for one of five residents reviewed for psychotropic medications (Resident R75). Findings include: Resident R75's clinical record revealed an admission date of 4/5/24, with diagnoses that included Alzheimer's Disease (brain disorder that slowly destroys memory, thinking skills, and, over time the ability to carry out the simplest tasks), Restlessness and Agitation (an inability to rest or relax because of anxiety), and Hyperlipidemia (high cholesterol). Review of Resident R75's medication orders revealed a physician's order dated 6/29/24, to administer Hydroxyzine (anti-anxiety) 25 milligrams (mg) Intramuscularly (an injection that goes into the muscle) every eight hours as needed for restlessness/agitation. Further review of physician's orders revealed an order dated 6/29/24, to administer Lorazepam (anti-anxiety) one mg Intramuscularly…

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 interviews, it was determined that the facility failed to label a multi-dose insulin (medication to treat elevated blood sugar levels) pen with the date it was opened, and discard an expired multi-dose insulin pen in one of four medication carts (Unit C), and failed to properly store medications for use for one of 25 residents reviewed (Resident R37). Findings include: Review of the facility policy entitled Medication Storage in the Facility dated [DATE], indicated medications and biologicals are to be stored safely, securely, and properly following manufacturerer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures should immediately be removed from stock, returned to ICP, and reordered from the pharmacy, if a current order exists. Observation on [DATE], at 3:20 p.m. revealed the Unit C medication cart contained two opened undated…

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, review of facility records, and resident and staff interviews, it was determined that the facility failed to provide sufficient staff with appropriate competencies to carry out the functions of the food and nutrition services in the kitchen. Findings include: Review of facility policy entitled Tray Service dated 12/26/23, revealed Procedure Hot and cold foods are attractively assembled on trays for resident. Responsible Cooks, Nutrition Services workers. Review of Job Description for Nutrition Services Assistant revealed Position Responsibilities Must meet job related competencies . and Knowledge, Skills and Abilities: .Serve-safe certification is preferred. Review of HCF SNF On The Job Training Program Trainee Packet Nutrition Services revealed Training Schedule: New staff member will work the schedule of their coach for the first five days. The initial three days will be hands-on with the coach and Trainee. Review of four weeks of dietary schedule revealed that there are four positions on the day shift and four positions on the evening shift. Review of the…

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

Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to use appropriate infection control practices for disinfection and storage of a graduate (measuring device) for one of 25 residents reviewed (Resident R6). Findings include: No facility policy provided. Resident R6's clinical record revealed an admission date of 2/20/24, with diagnoses that included atrial fibrillation (an irregular, often rapid rate that causes poor blood flow starting in the atria chamber of the heart), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), gastrostomy (a surgical procedure that creates an opening in the abdomen that allows a feeding tube to be inserted directly into the stomach), neuromuscular dysfunction of the bladder (a condition in people who lack bladder control due to a brain, spinal cord or nerve problem). Observations on 11/04/24, at 1:30 p.m. revealed a graduate sitting on Resident R6's bedside table with Tube 9/6/24 2100 written on it. During an interview on…

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

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to follow physician's orders related to oxygen equipment for one of two residents reviewed for oxygen usage (Resident R56). Findings include: Review of a facility policy entitled, Disposable Supply Changes dated 12/5/23, indicated that Guideline for when disposable supplies for medical equipment need changed for infection control purposes. Disposable supplies need to be dated when changed And Oxygen Cannulas [a thin tube with two prongs that fits into the resident's nostrils to deliver oxygen], Oxygen Supply Lines [tubing that connects from the oxygen source to the nasal cannula], and Oxygen Humidifier Bottles [plastic bottles filled with distilled water used to humidify oxygen] should be changed weekly or prn [as needed]. Resident R56's clinical record revealed an admission date of 8/30/22, with diagnoses that included Chronic Obstructive Pulmonary Disease, (COPD - a condition that obstructs air flow in the lungs with symptoms of difficulty…

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, observation, and staff interview, it was determined that the facility failed to provide appropriate urinary catheter (tubing inserted into the bladder to drain urine into a bag) care for one of two residents reviewed for catheters (Resident R57). Findings include: Review of Resident R57's clinical record revealed an admission date of 10/12/19, with diagnoses that included Obstructive and Reflux Uropathy (disorder where urine cannot flow through the urinary tract due to an obstruction and backs up into the kidneys), Retention of Urine (a condition where the bladder doesn't empty completely when urinating), and Overactive Bladder (a bladder control problem leading to a sudden urge to urinate). Review of Resident R57's clinical record revealed a physician's order dated 9/11/23, for an indwelling catheter. Observations on 12/26/23, at 12:40 p.m.; on 12/27/23, at 8:54 a.m.; and on 12/28/23, at 9:55 a.m. revealed that Resident R57's urinary drainage bag and tubing were lying on the floor. During an interview on 12/27/23, at 8:55 a.m. Registered Nurse…

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 records and resident, family members, and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for three of 20 residents reviewed (Residents R4, R5, and R17 ). Findings include: Review of the Resident Council minutes for July 2023 revealed concerns of resident meal trays are sitting too long; ice cream is melted. Resident Council Minutes for August 2023, revealed concerns of consistency of call bell positioning, filling water more frequently, asking both people in a room if they need water refilled, residents would like nursing to slow down and make sure needs are met, and better communication between shifts. Resident Council Minutes of September 2023, revealed concerns of call lights not being answered in a timely manner, trays are being left in resident rooms, food waiting on stackers in hallways for too long, staff at nursing station on their phones, not getting showers, would like more…

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 Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), clinical records and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set (MDS-federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment accurately reflected the status for one of 20 residents reviewed (Resident R12). Findings include: Review of the RAI manual instructions for Section M0300C1 Stage 3 Pressure Ulcers identified to code the number of currently present and whose deepest anatomical stage is a Stage 3. Review of Resident R12's clinical record revealed an admission date of 12/29/22, with diagnoses that included transient cerebral attack (stroke), hemiplegia (paralysis) and hemiparesis (partial paralysis) affecting left side and high blood pressure. Review of Resident R12's Quarterly MDS with an Assessment Reference Date (ARD) of 10/5/23,…

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.

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for one of 20 residents reviewed (Resident R12). Findings include: Review of a facility policy entitled, Comprehensive Care Planning, dated 12/15/22, indicated that the comprehensive care plans will periodically be reviewed and revised by a team of qualified persons as needed and after completion of each assessment. Review of Resident R12's clinical record revealed an admission date of 12/29/22, with diagnoses that included transient cerebral attack (stroke), hemiplegia (paralysis) and hemiparesis (partial paralysis) affecting left side and high blood pressure. Review of Resident R12's Quarterly MDS (MDS- periodic assessment of resident care needs) with an Assessment Reference Date (ARD) of 10/5/23, revealed that it was coded as having one Stage 2 (partial thickness, skin loss) pressure ulcer. Clinical record weekly wound documentation from a wound consultant company dated…

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

Based on review of facility documents and clinical records and staff interview, it was determined that facility staff failed to maintain complete and accurate clinical records for one of 20 residents reviewed (Resident R12). Findings include: Review of Resident R12's clinical record revealed an admission date of 12/29/22, with diagnoses that included transient cerebral attack (stroke), hemiplegia (paralysis) and hemiparesis (partial paralysis) affecting left side and high blood pressure. Review of Resident R12's Quarterly MDS (MDS- periodic assessment of resident care needs) with an Assessment Reference Date (ARD) of 10/5/23, revealed that it was coded as having one Stage 2 (partial thickness, skin loss) pressure ulcer. Clinical record weekly wound documentation from a wound consultant company dated 8/4/23 through 10/14/23, all revealed the presence of a Stage 3 (full- thickness, skin loss) pressure ulcer to the sacrum. Clinical record documentation entitled Nursing Wound Documentation Record dated 7/25/23 through 10/19/23, all indicated a Stage 2 pressure ulcer to the sacrum.…

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.