Cranberry Place

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals in a safe, secure, and orderly manner for three of four medication carts (North Unit Back Hall, [NAME] Unit Front Hall, and East Unit Front Hall). Findings include: Review of the facility policy Storage of Medications dated January 2026, indicated that medications and biologicals are stored safely, securely, and properly. During an observation on 1/28/26, at 9:31 a.m. of the North Unit Back Hall Medication Cart revealed the following: Resident R23's lantus pen (a prefilled pen that injects long-acting insulin under the skin), no open or expiration date noted. Resident R80's lantus pen, no open or expiration date noted. Resident R146's insulin lispro vial (a rapid-acting insulin, stored in a multi-dose vial), no open or expiration date noted. During an interview on 1/28/26, at 9:35 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the above observations and that the facility failed to properly store medications in the North…

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, clinical records, incident investigations, and staff interviews, it was determined that the facility failed to ensure that residents are free from misappropriation of property for one of five residents (Resident R155).Findings include: Review of the facility policy Recognizing Signs and Symptoms of Abuse/Neglect dated January 2026, indicated all types of resident abuse, neglect, exploitation, or misappropriation of resident property are strictly prohibited. Review of the clinical record indicated that Resident R155 admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 12/9/25, indicated diagnoses of peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), high blood pressure, and seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness). Section C0500 indicated a Brief Interview 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 clinical records and staff interview, it was determined that the facility failed to obtain a physician order for a wander guard for one of one resident (Resident R40) and failed to obtain a physician order for a colostomy for one of one resident (Resident R59).Findings include: Review of facility policy Physician Orders dated January 25, indicated the facility maintains a system for receiving, documenting, verifying, and carrying out physician orders. Review of the admission record indicated Resident R59 was admitted to the facility on [DATE], with diagnoses that included peripheral vascular disease (circulatory condition characterized by narrowed blood vessels), sepsis and anemia. Review of Resident R59''s Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/3/25, indicated the diagnoses remain current. Review of most recent plan of care for Resident R59 indicates the need for colostomy management. Review of Resident R59's physician's orders dated 1/12/26 revealed no orders…

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 the review of professional standards of practice, facility policy, clinical records, observation, and interviews with staff and resident, it was determined that the facility failed to make certain that residents received the necessary services to prevent/treat pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure to the skin) for two of three residents (Residents R83 and R156). Findings include: Review of the facility policy Physician Orders last reviewed January 2026, indicated that orders must be carried out as written and within the timeframe specified. Review of the admission record indicated Resident R83 was admitted to the facility on [DATE]. Review of Resident R83's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/23/26, indicated the diagnoses of high blood pressure, quadriplegia (paralysis affecting all four limbs) and neurogenic bladder (loss of bladder control). During an observation completed on 1/28/26, at 11:11 a.m. Resident R83…

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 two of four residents (Resident R8 and R34).Findings include: Review of the facility policy Administering Medications through a Small Volume Handheld Nebulizer dated January 2026, indicated the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. When treatment is complete, turn off nebulizer, rinse and disinfect the nebulizer equipment according to facility protocol. When equipment is completely dry, store it in a plastic bag with the resident's name and date on it. Review of the admission 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 12/19/25, indicated the diagnosis of respiratory failure (lungs can't get enough oxygen), Parkinson's disease…

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, clinical record review and staff interview the facility failed to provide sufficient and timely social services to meet the resident needs for one of three residents reviewed (Resident R33).Findings include: Review of facility policy dated 01/26, Referrals, Social Service indicated Social services personnel shall coordinate most resident referrals with outside agencies. Social services will document the referral in the resident's medical record. Review of facility documentation Social Worker job description indicated responsibilities document assessment, clinical team meeting minutes, and community resource referrals. Review of the clinical record indicated resident R33 was admitted [DATE]. Review of Resident R33's MDS (minimum data set a periodic review of assessment needs) dated 12/18/24, indicated diagnosis of heart failure and CAD. Review of Resident R33 clinical record psychiatric evaluation note dated 9/24/25, indicated Resident R33 says his mood is unchanged and he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to identify parameters for heart medication for one of three residents (Resident R5).Findings include: Review of facility policy Pharmacy Services Overview dated 01/26, indicated: Pharmaceutical services consist of: a. The process of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling, compounding, (e.g. intravenous antibiotics), dispensing, packaging, labeling, disturbing, administering, monitoring responses to, using and/or disposing of all medications, biologicals, chemicals;The provision of medication related information to health care professionals and residents;The process of identifying, evaluation, and addressing medication -related issues including the prevention and reporting of medication errors; andThe provision, monitoring and/or the use of medication -related devices.The facility shall contract with a licensed consultant…

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 and resident interviews, it was determined that the facility failed to ensure that a dental appointment was scheduled for one of six residents reviewed (Resident R59). Findings include:Review of the admission record indicated Resident R59 was admitted to the facility on [DATE]. Review of Resident R59''s Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/3/25, indicated diagnoses of peripheral vascular disease (circulatory condition characterized by narrowed blood vessels), sepsis and anemia. Documentation by the facility's contracted dental provider dated 11/21/25, indicated Resident R59 potentially has extraction(s) that are surgical in nature, need to consult with an Oral MaxillofacialSurgeon. Review of Resident R59's progress notes dated 11/25/25 indicated received list of oral surgeons from 360 care/ Social work director, calls placed to several to schedule for resident's teeth removal. During an interview on 1/30/26, at 1:30 p.m. Unit Manager…

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 regulations, documents submitted to the State agency and staff interviews, it was determined that the facility failed to notify the State agency of a change in the facility's Medical Director at the time of the change. Findings include:Review of the facility's data indicated Doctor Employee E16 was the Medical Director effective 9/1/22.During an interview on 1/28/26, at 1:00 p.m. the Nursing Home Administrator indicated Doctor Employee E16 no longer worked there, and the new Medical Director was Doctor Employee E17 effective June 2025.During an interview on 1/28/26, at 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to notify the State agency of a change in the facility's Medical Director at the time of the change.PA Code: 201.14(a) Responsibility of licensee.

Based on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings with all the required committee members for one of four quarters(Quarter Two on April 25, 2025). Findings Include: The facility Quality Assurance and Performance Improvement (QAPI) Program policy dated January 2026, indicated the Administrator/Executive Director is responsible for assuring that the QAPI Program complies with federal, state, and local regulatory agency requirements. Review of Quality Assurance and Performance Improvement sign in sheets and attendance records for Quarter Two of 2025, dated April 25, 2025, failed to indicate the Nursing Home Administrator was in attendance. During an interview on 1/28/26, at 11:00 a.m. the Nursing Home Administrator confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings with all the required committee members for one of four quarters(Quarter Two on April 25, 2025). 28 Pa Code:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that influenza immunization and pneumococcal immunization were offered to two of five residents (Residents R45, and R116).Findings include:Review of the facility policy Influenza Vaccine dated January 2026, indicated between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's/employee's medical record.Review of the facility policy Pneumococcal Vaccine dated January 2026 indicated all residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. For each resident who received the vaccine, the date 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, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Effective Communication for one of five staff members (Nurse Aide (NA) Employee E6).Findings include:Review of facility policy In-Service Training, All Staff dated January 2026, indicated all staff must participate in initial orientation and annual in-service training. Required training topics include the following: effective communication with residents and family, resident rights and responsibilities, preventing abuse, neglect, exploitation or misappropriation of resident property, elements and goals of the facility QAPI (Quality Assurance and Performance Improvement) program, the infection prevention and control program, behavioral health, and the compliance and ethics program. Review of NA Employee E6's personnel file indicated a date of hire on 7/28/24. Review of NA Employee E6's personnel file did not include annual in-service training on Effective Communication from 1/1/25 through 12/31/25. 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, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Resident Rights for one of five staff members (Nurse Aide (NA) Employee E6).Findings include:Review of facility policy In-Service Training, All Staff dated January 2026, indicated all staff must participate in initial orientation and annual in-service training. Required training topics include the following: effective communication with residents and family, resident rights and responsibilities, preventing abuse, neglect, exploitation or misappropriation of resident property, elements and goals of the facility QAPI (Quality Assurance and Performance Improvement) program, the infection prevention and control program, behavioral health, and the compliance and ethics program. Review of NA Employee E6's personnel file indicated a date of hire on 7/28/24. Review of NA Employee E6's personnel file did not include annual in-service training on Resident Rights from 1/1/25 through 12/31/25. 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, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program for one of five staff members (Nurse Aide (NA) Employee E6).Findings include:Review of facility policy In-Service Training, All Staff dated January 2026, indicated all staff must participate in initial orientation and annual in-service training. Required training topics include the following: effective communication with residents and family, resident rights and responsibilities, preventing abuse, neglect, exploitation or misappropriation of resident property, elements and goals of the facility QAPI (Quality Assurance and Performance Improvement) program, the infection prevention and control program, behavioral health, and the compliance and ethics program. Review of NA Employee E6's personnel file indicated a date of hire on 7/28/24. Review of NA Employee E6's personnel file did not include annual in-service training on the QAPI program 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, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Infection Control for one of five staff members (Nurse Aide (NA) Employee E6).Findings include:Review of facility policy In-Service Training, All Staff dated January 2026, indicated all staff must participate in initial orientation and annual in-service training. Required training topics include the following: effective communication with residents and family, resident rights and responsibilities, preventing abuse, neglect, exploitation or misappropriation of resident property, elements and goals of the facility QAPI (Quality Assurance and Performance Improvement) program, the infection prevention and control program, behavioral health, and the compliance and ethics program. Review of NA Employee E6's personnel file indicated a date of hire on 7/28/24. Review of NA Employee E6's personnel file did not include annual in-service training on Infection Control from 1/1/25 through 12/31/25. 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, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Compliance and Ethics for one of five staff members (Nurse Aide (NA) Employee E6).Findings include:Review of facility policy In-Service Training, All Staff dated January 2026, indicated all staff must participate in initial orientation and annual in-service training. Required training topics include the following: effective communication with residents and family, resident rights and responsibilities, preventing abuse, neglect, exploitation or misappropriation of resident property, elements and goals of the facility QAPI (Quality Assurance and Performance Improvement) program, the infection prevention and control program, behavioral health, and the compliance and ethics program. Review of NA Employee E6's personnel file indicated a date of hire on 7/28/24. Review of NA Employee E6's personnel file did not include annual in-service training on Compliance and Ethics from 1/1/25 through 12/31/25. 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, personnel files and staff interview it was determined that the facility failed to ensure that one of four sampled Nurse Aides (NA) received a minimum of 12 hours of in-service education per year (NA Employee E6).Findings include: Review of facility nurse aide training records revealed that NA Employee 6 did not receive 12 hours of in-service training from 1/1/25, through 12/31/25. The facility was unable to provide documented evidence that NA Employee E6 had received a minimum of 12 hours of in-service training yearly. During an interview on 1/31/26, at 9:08 a.m. the Director of Nursing confirmed that the facility failed to ensure NA Employee E6 received the required 12 hours of yearly in-servicing training. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff development.

Based on review of Resident Council meeting minutes, and staff interview it was determined the facility failed to consider the views of a resident group and act promptly on recommendations concerning issues of resident care and life in the facility for three of three months (September, October, and November 2025).Findings include: Review of a Resident Representative Concern dated 11/7/25, stated She was left unattended in a wheelchair with no remote near her to press for help. Review of Resident Council Meeting Minutes dated 9/11/25, stated Residents unanimously expressed that staff do not leave their call bells in reach. Review of Resident Council Meeting Minutes dated 10/9/25, stated Residents unanimously expressed that staff do not leave their call bells in reach. Review of Resident Council Meeting Minutes dated 11/13/25, stated Residents unanimously expressed that staff do not leave their call bells in reach (all units/all shifts). During an interview on 11/21/25, at 1:41 p.m. the Director of Nursing confirmed that the facility failed to address resident group response by 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 documents, facility policies, clinical records, and staff interviews, it was determined that the facility failed to conduct a thorough investigation of an allegations of abuse for one of two residents (Resident R26).Findings include: Review of facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated June 2025, indicated that all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. The individual conducting the investigation documents the investigation completely and thoroughly. Witness statements are obtained in writing, signed and dated. The witness may write his/her statement, or the investigator…

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 interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R24).Findings include:Review of facility policy Administering Medications dated June 2025, indicated medications are administered in a safe and timely manner, and as prescribed. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include:Checking identification band;Checking photograph attached to medical record; andIf necessary, verifying resident identification with other facility personnelThe individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.Review of the clinical record indicated Resident R24 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 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 have physician orders, resident specific care plans, and correct complete assessments for wander guards (a bracelet that alarms when close to an exit door) for four of four residents (Resident R4, R5, R6, and R7), and failed to accurately transcribe a medication upon admission for one of three residents (Resident R8). Findings include: Review of the facility Wandering and Elopements dated 6/1/25, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety. Review of the facility Reconciliation of Medications 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 policy, clinical record reviews, and staff interview it was determined that the facility failed to provide adequate supervision to prevent elopement for one of five residents (Resident R1). Findings include: Review of the facility Wandering and Elopements dated 6/1/25, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety. During an interview on 9/24/25, at 10:30 a.m. the Director of Nursing stated that residents should have orders for a wander guard, check placement of wander guard every shift, and check wander guard battery weekly if they are deemed at risk for elopement. Elopement assessments should be completed at least quarterly. Review of Resident R1's clinical record indicated 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 documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of three residents reviewed (Resident R3).Findings include: Review of the facility Abuse and Neglect - Clinical Protocol policy last reviewed 6/2025, indicated the nurse will assess the individual and document related findings; Abuse, is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled…

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 in the main kitchen, and staff interview, it was determined the facility failed to properly date and store food products in a manner to prevent foodborne illness in the main kitchen (Main Kitchen). Findings include: The facility Food safety program: standard operating procedures policy last reviewed 6/1/25, indicated that the foodservice director will be responsible for monitoring the overall performance of operating procedures. Food safety checklist includes all food stored or prepared in the facility from approved sources. All food is properly wrapped, labeled and dated. During observations of the main kitchen on 7/7/25, the following was observed: -At 9:08 a.m. a refrigerator/cooler by tray line was observed with turkey breast lunch meat, ham lunch meat, provolone sliced cheese, and Swiss sliced cheese. Each was observed open and without an open date. -At 9:17 a.m. observations of the dry storage room found four bags of open pasta and one container of graham cracker crumbs open and without an open date. During an exit 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 review of facility policy, resident clinical records, and staff interview, it was determined that the facility failed to complete comprehensive wound assessments weekly for one out of seven sampled residents (Resident R1). Findings include: The facility Wound care policy last reviewed 6/1/25, indicated that the following information should be recorded in the resident's medical record: all assessments data (wound's color, size, drainage) obtained when inspecting the wound. The facility Skin care and wound management guidelines dated 8/11/23 and last reviewed 6/1/25, indicated that wound assessments are required at a minimum weekly and when there is a change. Review of Resident R1's admission record indicated he was originally admitted on [DATE], and re-admitted [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of resident care needs) date 6/18/25, indicated he had diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical record, and staff interview, it was determined that the facility staff failed to provide medications and treatments as ordered by the physician for two of 6 residents (Resident R1 and Resident R2). Findings include: Review of facility policy Administering Medications, reviewed August 2024, indicated medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted to prepare, administer and document the administration of medications may do so. Medications are administered in accordance with prescriber orders, including required time frame. Review of facility policy Medication and Treatment Order, reviewed August 2024, indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to such an order. Drugs and biologicals that are required to be refilled must be…

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 interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R1). Findings include: Review of facility policy Administering Medications dated August 2024, indicated that the individual administering the medication records in the resident medical records the following information: · The date and time the medication was administered. · The dosage · The route of administration. · The injection site (if applicable). · Any complaints or symptoms for which the drug was administered. · Any results achieved and when those results were observed: and · The signature and title of the person administering the drug. Review of facility policy Medication and Treatment Orders dated August 2024, indicated that drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three days prior to the last…

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 revise/update care plans for three of three residents to accurately reflect the current status of the residents' needs (Residents R1, R2, and R3). Findings include: Review of the facility policy Care Plans, Comprehensive Person-Centered dated August 2024, indicated the facility must develop a comprehensive Person-Centered Care Plan for each resident that includes measurable objectives and timeframes and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Care plans are revised as information about the residents and residents' condition change. Review of 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 3/24/25, indicated the diagnoses of diabetes (a long-term condition in which…

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

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 are free from significant medication errors for one of three residents (Resident R1). Findings include: Review of facility policy Administering Medication dated 8/1/24, indicated that medications are administered in a safe and timely manner, and as prescribed. Review of facility policy Resident Rights dated 8/1/24, indicated that all residents shall be treated with kindness, respect, and dignity. Resident will be informed of his or her medical condition and of any changes in his or her condition. Review of Resident R1's admission record indicated resident was admitted on [DATE], and discharged home on 2/7/25. Review of Resident R1's MDS assessment (minimum data set - a periodic assessment of resident care needs) dated 1/28/25, indicated diagnoses that included chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory…

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 interviews, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of four residents sampled with facility-initiated transfers (Residents R70, R76, and R115). Findings include: Review of the clinical record indicated Resident R70 was admitted to the facility on [DATE]. Review of Resident R70's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/9/24, indicated diagnoses of cancer (abnormal cells form tumors in healthy tissue), depression, and peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of Resident R70's clinical record revealed that the resident was transferred to the hospital on [DATE]. Review of Resident R70's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for 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 policy, clinical records, and resident and staff interview, 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 three of four resident hospital transfers (Residents R70, R76, and R115). Findings Include: Review of the facility policy Bed-Holds and Returns dated August 2024, indicated all residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospital or therapeutic leave). Residents are provided written information about these policies at least twice: well in advance of any transfer (e.g., in the admission packet); and at the time of transfer (or, if the transfer was an emergency, within 24 hours.) Review of the clinical record indicated Resident R70 was admitted to the facility on [DATE].…

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 notify a physician of abnormal glucose readings and lab results as per order for three of six residents (Residents R67, R77, and R167) and failed to follow a physician order for two of five residents (Resdient R67, and Resident R115). Findings include: Review of the facility policy Medication and Treatment Orders dated August 2024, indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. Review of facility policy Management of Hypoglycemia dated 8/24, indicated the purpose is to provide guidelines for managing hypoglycmia (low blood sugar) to insulin therapy or therapy with oral hypoglycemic agents in the diabetic resident. Symptoms of hypoglycemia (low blood sugar level) may include: - Weakness, dizziness, or fainting - Restlessness and/or muscle twitching - Increased heart rat - Pale, cool, moist skin - Excessive sweating -…

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, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for four of five residents (Residents R40, R53, R70, and R103). Findings include: Review of facility policy Enteral Tube Feeding via Continuous Pump dated 8/24, indicated the purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings. Check the enteral nutrition label against the order before administration. Check the following information: - Residents name, ID, and room number - Type of formula - Date and time formula was prepared - Rate of administration Review of Resident R40's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R40's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/1/25,…

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 provide appropriate respiratory care and maintain oxygen equipment for five of six residents (Residents R2, R70, R77, R103, and R317). Findings include: A review of the facility policy Respiratory Therapy last reviewed on 8/24, indicates to guide prevention of infection associated with respiratory therapy task and equipment, including ventilators, among residents and staff. Steps in the procedure include but not inclusive to: . Change the oxygen cannula and tubing every 7 days or as needed. . Wash filters from oxygen concentrators every 7 days with soap and water. Rinse and squeeze dry. . Store the circuit in plastic bag, marked with date and residents name, between uses. A review of Resident R2's clinical record indicate an admission date of 7/6/23. A review of R2's Minimum Data Set (MDS-periodic assessment of care needs) dated 11/7/24, indicate the diagnosis of anemia (low iron…

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 personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for four out of four nurse aide personnel records (Nurse Aides (NA) Employee E16, NA Employee E17, NA Employee E18, and NA Employee E19). Findings include: Review of facility policy In-Service Training, Nurse Aide dated August 2024, indicated the facility completes a performance review of nurse aides at least every 12 months. Review of NA Employee E16's personnel record indicated a hire date of 2/6/23. Review of NA Employee E17's personnel record indicated a hire date of 7/25/22. Review of NA Employee E18's personnel record indicated a hire date of 7/30/12. Review of NA Employee E19's personnel record indicated a hire date of 2/7/22. Review of personnel records did not include annual performance evaluations based on the date of hire for NA Employee E16, NA Employee E17, and NA Employee E18, and NA Employee E19. Interview on 1/23/25, at 2:21 p.m. the Nursing Home Administrator confirmed that the facility failed to complete annual performance…

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 residents clinical record, resident and staff interview it was determined that the facility failed to meet resident rights for one of 10 residents reviewed (Resident R94). Findings include: Resident R94 was admitted on [DATE]. Resident R94 MDS (minimum data set - a periodic assessment of resident needs) dated 11/13/24, indicated diagnoses diabetes mellitus (a group of diseases that result in too much sugar in the blood), anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily life). During an interview on 1/23/25, Resident R94 indicated that they were interested in switching beds from the door bed, to the window bed (which was empty due to roommate being discharged ). Resident R94 indicated that they spoke with staff about it and the facility was going to switch 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 review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide documentation of advanced directives or given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of four residents reviewed (Resident R70, and R77). Findings include: A review of the facility policy Advanced Directives last reviewed 8/24, indicated that the resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment. Advanced directives are honored in accordance with state law and facility policy. The resident or representative is provided with written information concerning the right to formulate an advanced directive in a manner that is easily understood. Review of Resident R70's clinical record indicated the resident was admitted to the facility on [DATE]. Review of 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 review of facility policy, clinical records and staff interview, it was determined that the facility failed to notify the physician of a resident's refusal of tube feedings for one of four residents (Resident R50). Findings include: Review of the facility policy Guidelines for Notifying Physicians of Clinical Problems last reviewed 8/24, indicated medical care problems are communicated to the medical staff in a timely efficient and effective manner. Review of the facility policy Enteral Tube Feeding via Continuous Pump last reviewed 8/24, indicates to report negative consequences of tube use (e.g., agitation, depression, self-extubating, infections etc.) to the supervisor and attending physician. Review of the facility policy Enteral Feedings-Safety Precautions last reviewed 8/24, indicates report unusual findings and/or signs of complications to the physician. Review of the clinical record indicated that Resident R50 was admitted to the facility on [DATE], with the diagnosis of quadriplegia (paralysis…

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) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) forms and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands for one of three residents (Resident R27). Findings include: 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 intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R27's admission record indicated the resident was admitted to the facility 7/15/24. Review of Resident R27'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, observations, resident and staff interviews it was determined that the facility failed to make certain that a posted grievance policy and procedure met federal guidelines for three of three nursing units and common areas. Findings include: The facility Grievance Program (Concern and Comment) dated 8/20/24, indicated To help guide our communities in the grievance process and ensure that a thorough, complete, and accurate investigation has been completed to the best of our knowledge in accordance with F585 483.10(j)(1)(2)( 3) and (4). Resident group interview on 1/22/25, at 3:00 p.m. resident indicated they were unaware of the grievance policy, and procedure how they could file anonymously. During a tour on 1/23/25, at 9:57 a.m. on 3 nursing units and common areas to include the main dining room, nursing unit lounge areas, failed to have a complete grievance policy and procedure posted and failed to have a posting with the grievance officer address included on the posting, failed to include how to file anonymously, failed to include the process…

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 and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to permit one of three residents who transferred to the hospital with the expectation of returning to the facility, return to the facility in a timely manner. (Resident R50) Findings include: Review of the facility policy Bed-Holds and Returns dated August 2024, indicates residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed hold policies. The written information regarding bed-holds provided to the residents/representatives explains in detail: a. The duration of a state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the facility. b. The reserve bed payment as indicated by the state plan. c. The facility policies regarding bed-hold periods. d. The facility per diem rate required to hold a bed (for a non-Medicaid residents), or to hold a bed beyond the state bed hold period…

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 the facility failed to update a care plan for three of ten residents (Residents R1, R50, and R115) to accurately reflect the current status of the resident and care needs. Findings include: Review of the facility policy Care Plans, Comprehensive Person-Centered dated August 2024, indicated the facility must develop a comprehensive Person-Centered Care Plan for each resident that includes measurable objectives and timeframes and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Care plans are revised as information about the residents and residents' condition change. The interdisciplinary team reviews and updated the care plan: a. when there has been a significant change in resident's condition; b. when the desired outcome is not met: c. when the resident has been readmitted to the facility from a hospital stay; and d. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision for two residents resulting in elopement (resident exited to an unsupervised or unauthorized location without staff's knowledge) for two of two residents (Residents R42, and R114), and failed to follow a prescribed diet order for one of three residents (Resident R50). Findings include: Review of the facility policy Wandering and Elopements dated August 2024, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm. Review of the facility policy Assistance with meals dated August 2024, indicates residents shall receive assistance with meals in a manner that meets the individual need of each resident. Residents with feeding tubes, nursing staff will provide feedings to tube feed residents. Review of the facility policy Therapeutic Diets dated August 2024, indicated therapeutic diets are…

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 facility polices, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for three of six residents (Resident R3, R62 and R317) and failed to update a care plan for one of three residents (R317) to accurately reflect the current status of the resident and care needs. Findings include: Review of facility policy Dignity dated 8/24, indicated that each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Review of Resident R3's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R3's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 12/8/24, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking 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 and clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for one of two dialysis residents (Resident R1). Findings include: Review of the facility policy End-Stage Renal Disease, Care of a Resident with dated August 2024, indicated residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Agreements between the facility and the contracted ESRD facility will include how communication between the dialysis provider and facility staff will occur. Review of Resident R1's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/6/24, indicated diagnoses of peripheral vascular disease (progressive disorder that causes narrowing or blocking of the blood vessels outside of the heart), heart failure, and dependence on renal…

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 and staff interview and clinical record review the facility failed to maintain the highest practicable mental and psychosocial well-being for one of three residents (Resident R94). Findings include: Review of the facility policy Social Services dated 8/20/24, indicated: Our facility provides medially-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. The social worker/social services staff are responsible for: making referrals and obtaining needed services from outside entities Resident R94 was admitted on [DATE]. Resident R94 MDS (minimum data set - a periodic assessment of resident needs) dated 11/13/24, indicated diagnoses diabetes mellitus (a group of diseases that result in too much sugar in the blood), anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), 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, observation and staff interview it was determined the facility failed to dispose or reconcile discontinued medication in a timely manner for one of two medication rooms reviewed (West Medication Room). Findings: Review of facility Storage of Medications policy dated 8/24, indicated that the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity control. Only persons authorized to prepare and administer medications have access to locked medications. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Review of facility Discarding and Destroying Medication policy dated 8/24, indicated that medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous [NAME], and controlled…

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 review and clinical record review, and staff interview, it was determined that the facility failed to make certain that residents receiving psychotropic medications have adequate indication for use for one of five sampled residents (Resident R108). Findings include: Review of the facility policy Medication and Treatment Orders dated August 2024, indicated orders for medications must include name and strength of the drug, number of doses, dosage and frequency of administration, route, clinical condition for which the medication is prescribed. Review of the admission record indicated Resident R108 was admitted to the facility on [DATE]. Review of Resident R108's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/5/25, indicated the diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn't pump blood as well as it should), high blood pressure, and anxiety disorder. Review of Resident R108's physician orders dated 12/30/24, indicated quetiapine…

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, and staff interviews, it was determined that the facility failed to properly store medical supplies in two of four medication carts (North Front Med Cart, and [NAME] Med Cart) and failed to properly store medical supplies and biologicals in one of two medication rooms (North medication room). Findings: Review of facility Storage of Medications policy dated 8/24, indicated that the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity control. Only persons authorized to prepare and administer medications have access to locked medications. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Insulin pens are clearly labeled with the resident's name. During a medication cart review on [DATE], at 9:45 a.m. the narcotic lock box on the North Front 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 facility policy, observation, and staff interviews, it was determined that the facility failed to provide food in a form to meet individuals' needs in one of three residents ordered a soft and bite size diet (Resident R42). Findings include: Review of the facility policy Therapeutic Diets dated 8/24, indicated that therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. A therapeutic diet is considered a diet ordered as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet. Review of the clinical record revealed that Resident R42 was admitted to the facility on [DATE]. Review of Resident R42's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 12/6/24, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), 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 meal delivery times, observations and staff interview, it was determined that the facility failed to deliver meals in a timely manner for one of two meal observations (West Rooms 374-387). Findings include: Review of the facility provided tray schedule, indicated lunch start time is at 11:00 a.m. More specifically, [NAME] 2 (Rooms 374-387) cart number 8 is 12:05 p.m. During dining/meal observations on 1/21/25, at 12:00 p.m. of the [NAME] Hallway Rooms 374-387, it was revealed that the lunch trays did not arrive until 12:32 p.m. Trays arrived 27 minutes late. Interview on 1/21/25, at 12:33 p.m. Nurse Aide (NA) Employee E20 confirmed the time of tray arrival to be 12:32 p.m. Interview on 1/21/25, at 12:40 p.m. Registered Nurse (RN) Employee E21 indicated tray arrival time varies since the change in management, and the loss of multiple dietary personnel. During an interview on 1/24/25, at 3:15 p.m. the Director of Nursing confirmed the facility failed to deliver meals in a timely manner for one of two meal observations (West Rooms 374-387). 28 Pa. Code:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and staff interviews it was determined that the facility failed to provide adaptive feeding devices for one of three residents (Resident R42). Findings include: Review of the admission record indicated Resident R42 admitted to the facility on [DATE]. Review of Resident R42's Minimum Data Set (MDS- a periodic assessment of care needs) dated 12/6/24, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking). Review of Resident R42's current physician orders indicated a soft and bite size diet with thin liquids. Review of Resident R42's care plan dated 1/20/25, indicated to use a two handled sippy cup with spout, sippy lid. During an observation on 1/22/25, at 12:15 p.m. Resident R42 was in the dining room set up for lunch and was eating. The meal ticket indicated spouted cup. During an interview and observation on 1/22/25, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to maintain proper infection control practices related to care of indwelling urinary catheters (tube inserted in the bladder to drain urine) for one of three residents reviewed (Residents R53), failed to prevent cross contamination during a dressing change for one of three residents (Resident R54) and failed to follow enhanced barrier precautions for one of five residents (Resident R54). Findings include: Review of facility policy Catheter Care, Urinary, dated August 2024, indicated this procedure is to prevent catheter-associated complications, including urinary tract infections. Be sure the catheter tubing and drainage bag are kept off the floor. Review of the facility policy Dressings, Dry/Clean, dated August 2024, indicates the purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Steps in the procedure (1 thru 24) include but not inclusive to: Step…

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, observations, and resident and staff interviews, it was determined that the facility failed to provide a homelike environment for three of three nursing units (North Wing, East Wing, and South Wing). Findings include: Review of facility policy Resident Rights, reviewed 1/2/24, indicated that residents have the right to a safe, clean, comfortable and homelike environment. During a group interview on 1/30/24, at 1:10 p.m., it was noted that the Dining Room has not been open for residents to eat in since COVID 19 started in 2020. During an observation at lunchtime on 1/29/24, 1/30/24, 1/31/24, and 2/1/24, no residents were present in the Dining Room. During an interview on 1/31/24 at 2:40 pm. Nursing Home Administrator (NHA) confirmed that the facility had one Dining Room that was to accomodate residents from all three unit, but had not been open regularly since COVID 19 and that it was only open briefly in 2023 for a very short time. NHA confirmed that the facility failed to provide a homelike environment for residents in three of three nursing units (North…

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 maintain ongoing communication with the dialysis (a machine filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for three of three residents receiving dialysis (Resident R46, R216, and R218). Findings include: Review of facility policy Hemodialysis Coordination of Care dated 1/2/24, indicated the facility staff are responsible for communicating resident's medical condition and pretreatment vital signs to the dialysis center staff before treatment as ordered. Review of the clinical record indicated Resident R46 was admitted to the facility on [DATE]. Review of Resident R46's Minimum Data Set (MDS - a period assessment of care needs) dated 1/11/24, indicated diagnoses of high blood pressure, end stage renal disease (ESRD - an inability of the kidneys to filter the blood), and hip fracture. Section O, Question…

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 Group interviews, Resident Council meeting minutes, grievances, and staff interview it was determined the facility failed to consider the views of a resident and/or family and act promptly on grievances and recommendations concerning issues of resident care and life in the facility for nine of twelve months (January, February, March, April, May, June, July, August and September 2023). Findings include: Review of facility policy titled Resident Rights-Grievance, last reviewed 1/2/24, indicated prompt efforts to resolve grievances. The intent of the grievance process is to support each resident's right to voice grievances and to assure that after receiving a complaint/grievance the facility actively seeks a resolution and keeps the resident appropriately apprised of its process toward a resolution. During a Resident Group meeting held on 1/30/24, eight of eleven members voiced concerns over not receiving resolutions to their concerns during resident council meetings. Review of Resident Council meeting minutes on the following dates 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 clinical record review, staff interview and observations it was determined the facility failed to ensure the privacy of the resident while providing care for two of four residents observed (Resident R26, and R108). Findings Include: Review of facility policy Personal Care and Privacy dated 1/2/24, indicated to maintain privacy and dignity during personal hygiene and/or procedures. Review of the admission record indicated Resident R26 was admitted to the facility on [DATE]. Review of Resident R26's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/8/23, indicated the diagnoses of diabetes (too much sugar), high blood pressure, and coronary artery disease (narrow arteries decreasing blood flow to the heart). Review of Resident R26's physician order dated 1/5/24, indicated to inject Lantus insulin (medication shot to regulate sugar) every morning. Observation on 1/31/24, at 8:25 a.m. Resident R26 was lying in bed in a night gown. Registered Nurse (RN) Employee E2 pulled up the 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.

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 implement the facility abuse policy for one of three abuse allegations (Resident R62). Findings include: Based on review of facility policy, clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to report an allegation of verbal abuse in the required timeframe for one of three residents (Resident R62). Findings include: Review of facility policy Abuse Neglect Exploitation dated 1/2/24, indicated the facility shall provide a safe environment where residents are protected from all forms of abuse and strive to achieve a culture that treats every resident with dignity and respect. Through seven major elements of screening, training, prevention, identification, investigation, protection, and reporting, the facilities act to prevent abuse. In the event an incident that meets or has the potential to meet one of the definitions…

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, reports submitted to the State, and staff interview, it was determined that the facility failed to report an allegation of verbal abuse in the required timeframe for one of three residents (Resident R62). Findings include: Review of facility policy Abuse Neglect Exploitation dated 1/2/24, indicated the facility shall immediately report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes. In the event an incident that meets or has the potential to meet one of the definitions stated in the policy on abuse or neglect of a resident is reported to the Administrator or designee, an investigation of the incident will be commenced immediately. The Administrator and/or Director of Nursing will ensure that all alleged or suspected violations involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of elder property are…

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 for one of three residents (Resident R46). Findings include: Review of facility policy Accidents and Incidents dated 1/2/24, indicated all accidents and incidents involving residents will be reported and investigated as indicated. When a resident incident/accident occurs the resident will be assessed by a Nurse. The Charge Nurse or designee will complete an assessment noting witnesses, if applicable, and that the family and physician were notified. Review of facility policy Abuse Neglect Exploitation dated 1/2/24, indicated incidents in which a resident has been injured or had the potential for injury and the cause of the incident is unknown should be promptly investigated. The following individuals may be considered when interviewing/investigating: the person making the report, individuals alleged 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 develop a plan of care to include a focus and interventions for one of three residents' tube feeding (R102), and one of two residents' (R108) parenteral feeding in order to maintain a resident's highest practicable physical well-being as required. Findings include: Review of facility policy Resident Centered Care Plan, dated 1/2/24, indicated that the care plan process defines clinical care goals and expectations for each resident, including identification of specific programs appropriate for the resident such as restorative or rehabilitation care. The care plan will be individualized for each resident based upon all available resident specific information including, but not limited to identified clinical and functional goals, approaches and interventions, and physician's orders Review of the clinical record revealed that Resident R102 was admitted to the facility on [DATE]. 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 facility policy, clinical record review, and staff interviews, it was determined that the facility staff failed to follow physician's orders for one of two residents (Resident R62) with a ventricular assist device (VAD - a device that provides support for cardiac circulation, either partially or completely replacing the function of a failing heart). Findings include: Review of facility policy Care of Resident with Ventricular Assist Device dated 1/2/24, indicated care of the patient may include details such as assessment of the patient cardiac status by obtaining a blood pressure with a doppler, respirations, temperature, edema, weight, redness, draining, or foul odor at the driveline site (insertion site of the device into the body), pain and anxiety. Monitor Device Flows (Cardiac Output). Upon admission, follow all basic care protocols as ordered for residents with a VAD. Review of the clinical record indicated Resident R62 was admitted to the facility on [DATE]. Review of Resident R62'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 interview, it was determined that the facility failed to provide a safe environment resulting in a fall during a transfer for one of three residents (Resident R46). Findings include: Review of facility policy Accidents and Incidents dated 1/2/24, indicated all accidents and incidents involving residents will be reported and investigated as indicated. The purpose is to promote a safe environment for all residents, report occurrences appropriately and review and analyze for the opportunity for preventive measures. When a resident incident/accident occurs the resident will be assessed by a Nurse. The Charge Nurse or designee will complete an assessment noting witnesses, if applicable, and that the family and physician were notified. Review of the clinical record indicated Resident R46 was admitted to the facility on [DATE]. Review of Resident R46's Minimum Data Set (MDS - a period assessment of care needs) dated 1/11/24, 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 a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to assure that licensed nurses displayed the appropriate competencies and skills necessary to provide care to two of two residents (Resident R62 and R81) with a ventricular assist device (VAD - a device that provides support for cardiac circulation, either partially or completely replacing the function of a failing heart). Findings include: Review of facility policy Care of Resident With Ventricular Assist Device dated 1/12/24, indicated for each resident with a VAD, coordination with the Artificial Heart Program is required and includes facility staff education, specifics of resident's care and equipment, specifics for notification of Artificial Health Team, including contact numbers, and additional information specific to resident and/or device. Care of the patient may include details such as assessment of the patient cardiac status by obtaining a blood pressure with a doppler,…

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, clinical record and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of four residents (Resident R108). Findings include: Review of the policy SRC-Pharmacy-12.8 Medication Administration: General dated 1/2/24, indicated the facility will provide a safe, effective medication administration process and verify the medication order for the right resident, right drug, right dose, right route, and right time. Review of the policy SRC-Pharmacy-12.10 Medication Administration: Injectables dated 1/2/24, indicated to administer an IM (intra-muscular) injection, the deltoid muscle may be used for a small volume injection two milliliters or less. Position the syringe at a 90 degree angle to the skin surface with the needle a couple inches from the skin. Quickly and firmly thrust the needle through the skin deep into the muscle. Pull back the plunger slightly to check for blood return.…

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 label open medications with a date in one of four medication carts (West Back Hall). Findings include: Review of facility policy Medication Storage dated 1/2/24, indicated all medications are maintained under strict conditions according to accepted standards of practice. An observation on 1/31/24, at 9:02 a.m. of the [NAME] Back Hall medication cart revealed the following medications not dated upon opening: - Resident R12's Advair (inhaled medication used to treat shortness of breath) inhaler. - Resident R14's Combivent (inhaled medication used to treat shortness of breath) inhaler. - Resident R15's NovoLog pen (prefilled pen to inject rapid-acting insulin under the skin). - Resident R15's Tresiba pen (prefilled pen to inject long-acting insulin under the skin). - Resident R81's Lantus pen (prefilled pen to inject long-acting insulin under the skin). During an interview on 1/31/24, at 9:08 a.m. Registered Nurse Employee E1 confirmed the findings noted above. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and a review of the facility's assessment and resident census and condition it was determined that the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for its specific resident population. Findings include: Review of the policy SRC-Administration-Facility Assessment dated 1/2/24, indicated the facility assessment must address or include: - The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. -The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population. Review of the admission record indicated Resident R91 was admitted to the facility on [DATE]. Review of Resident R91's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/24/23, indicated the 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.

Based on a review of facility policy, plans of correction and the results of the current and former surveys, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: Review of the facility policy Quality Assessment/Performance Improvement, dated 1/2/24, indicated that the facility will utilize a QAPI program to comprehensively address systems of care and management practices to provide safe and high quality care utilizing data and the best available evidence to define and measure goals. QAPI activities are designed to systematically monitor and evaluate the quality and appropriateness of resident care and services. The QAPI committee is responsible for making recommendations for improvement when negative trends or problems are identified. The facility implements systems to monitor care and services from multiple sources including clinical outcome results, input 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for seven of thirteen residents: three of three residents ordered daily weights (Resident R1, R2, and R3), two of five residents with dressing change orders (Resident R4 and R5), and three of six residents with orders for TED hose (specially designed stockings that help prevent blood clots and swelling in the legs) (R4, R6, and R7). Findings include: Review of the facility policy, Skin Integrity and Wound Management dated January 2023, indicated the facility will provide safe and effective skin and wound care, to provide the development of wounds or any insult to skin integrity, to manage safe and appropriate treatment, and to promote healing. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of 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 review of clinical records, and staff interview it was determined that the facility failed to notify the resident's representative of a change in prescribed medication treatments for one of five resident records (Closed Resident Record CR1). Findings include: Review of Closed Resident Record CR1's was admitted on [DATE], with diagnoses that included encephalopathy (a broad term for any brain disease that alters brain function or structure), cellulitis (bacterial infection of the skin causing redness, aches, and swelling), hyponatremia (low concentration of sodium in the blood), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry) urinary tract infection (infection in any part of the kidneys, bladder or urethra), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body); protein-calorie malnutrition (lack of sufficient nutrients in the body), and hypertension (a condition impacting blood circulation through 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.