Inners Creek Skilled Nursing And Rehabilitation Ce

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility provided documentation review, and staff interviews it was determined that the facility failed to provide adequate supervision and assistance to prevent accidents for one of three residents reviewed (Resident 4). Review of facility policy titled NSG215 Falls Management with a last revision date of March 15, 2024, revealed 2. Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. 2.1 Adjust and document individualized intervention strategies as patient condition changes. 4.Educate staff, patient, and/or patient representative(s) as appropriate to increase awareness of 'at risk' patients and to provide possible strategies to minimize risk for falls. Review of Resident 4's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), Vitamin D deficiency, muscle…

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

Based on policy review, staff interview, and other documents review, it was determined that the facility failed to ensure food is served at a safe and appetizing temperature for one meal test tray completed (lunch meal). Findings Include: Review of the facility's policy, titled Food Handling, revised January 26, 2024, read, Foods are stored, prepared, and served in a safe and sanitary manner. The purpose of the policy read To prevent bacterial contamination and the possible spread of infection. The policy continued, food must remain at 135 [degrees] or above. Review of the facility's document titled Resident Council Minutes, dated May 1, 2025, revealed that residents reported concerns about the temperatures of food, and residents reported trays are cold. An interview with Employee 3 (Dietary Manager) on June 9, 2025, at 9:30 AM, revealed an awareness of the resident concerns regarding food temperatures. The interview revealed the facility has requested the replacement of a food/plate warmer to keep food at a safe and palatable temperature at delivery. An observation of a lunch meal…

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

Based on policy review, resident and staff interviews, and clinical record review, it was determined that the facility failed to ensure its residents the right to exercise his or her rights as a resident of the facility and as a citizen of the United States for voting in one election (local election) for three of four residents interested in voting (Residents 2, 5, and 6). Findings Include: Review of the facility's policy, titled Resident Rights Under Federal Law, revised February 1, 2023, revealed a purpose to Treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her self-esteem and self-worth. To incorporate the resident's goals, preferences, and choices into care. To recognize each resident's individuality as well as honor and value his/her input. To protect and promote the rights of the resident. Review of Resident 2's interdisciplinary plan of care revealed an activity preference that read It is important for me to vote, and I prefer to vote by absentee ballot while 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.

Based on facility policy review, job description review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of four residents reviewed (Resident 1). Findings Include: Review of facility policy, titled NSG122 Change in Condition: Notification of, revised July 1, 2024, revealed A center must immediately inform the patient, consult with the patient's physician, and notify, consistent with their authority, the patient's representative, where there is: .A significant change in the patient's physical mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); . or A decision to transfer or discharge the patient from the Center. Review of facility job description for the Licensed Vocational Nurse (LVN), also known as the Licensed Practical Nurse (LPN), revealed Under the direction of a Registered Nurse (RN), the Licensed Vocational Nurse delivers…

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

Based on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure each resident recieves adequate supervision and assistance to prevent accidents and hazards for one of three residents reviewed (Resident 1). Findings Include: Review of the facililty's policy, titled Elopement of Patient, recently revised October 24, 2022, defined elopement as .any situation in which the patient leaves the premises without the facility's knowledge and supervison . Review of Resident 1's clinical record revealed diagnoses that inlcuded Post Traumatic Stress Disorder (PTSD - A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. The condition may last months or years, with triggers that can bring back memories of the trauma accompanied by intense emotional and physical reactions) and bipolar disorder (a mental illness characterized by extreme and unusual shifts in mood, energy, and activity levels). Review of Resident 1's clinical record revealed a progress note dated March 25, 2025, that read…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the physician reviews the resident's total program of care, including medications, for one of three residents reviewed (Resident 1). Findings Include: A review of Resident 1's clinical record revealed diagnoses that included bilateral knee osteoarthritis (a degenerative joint disease that causes the cartilage and bone in your joints to break down over time. It's the most common type of arthritis and can affect the hands, hips, knees, back, and other joints) and muscle weakness. A review of Resident 1's consultation form dated November 13, 2024, with an Orthopaedic Surgery Specialist ([NAME]), revealed recommendations that included a new order for Tylenol 1000 mg (milligrams) Q (every) 8 hours. A review of Resident 1's physician's orders revealed the Resident was already receiving Tylenol with an order that read Tylenol 8-hour oral tablet extended release three times a day for pain. Do not exceed [more than]…

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, policy review, and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing services to assure resident safety or maintain the highest practicable physical well-being of each resident for one of three residents reviewed (Resident 1). Findings Include: A review of the facility's Registered Nurse Job Description, revised June 16, 2017, read, in part, The Registered Nurse [RN] delivers efficient and effective nursing care while achieving positive clinical outcomes and patient/family satisfaction. He/she operates within the scope of practice defined by the State Nurse Practice Act . The RN manages patient care by performing nursing assessments and collaborating with the nursing team and other disciplines .to develop effective plans of care. A review of the facility's policy, titled Medication Administration, dated January 2024, read, in part, Medications are administered in…

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 contract review, clinical record review, and staff interviews, it was determined that the facility failed to ensure the radiological diagnostic studies were done in a timely manner consistent with physician's orders for two of three residents reviewed (Residents 1 and 2). Findings include: Review of facility contract with their selected radiology provider dated January 1, 2023, revealed A stat service is provided for critical situations requiring rapid results, and 'STAT' orders shall be honored by Provider only when requested by the physician or non-physician practitioner. Customer [the facility] shall use its best efforts to limit 'STAT' orders to urgent situations where the absence of such an order could reasonably be believed to place the Patient's health in serious jeopardy or resulting serious bodily impairment or dysfunction. Review of Resident 1's clinical record revealed that they were admitted to the facility on [DATE], with diagnoses that included surgical repair of a displaced…

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 and procedures reviews, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the physician was promptly notified of abnormal x-ray results for one of three residents reviewed (Resident 2). Findings include: Review of facility policy, titled 5.8 Physician Notification, dated December 1, 2006, indicated, in part, 3. If resident's condition indicates urgent physician notification; 3.1 Notify physician immediately; 3.1.2 Report all pertinent data. Review of facility policy, titled NSG115 Physician/Advanced Practice Provider (APP) Notification, with a last revised date of December 1, 2021, revealed Upon identification of a patient who has a change in condition, abnormal laboratory values, or abnormal diagnostics, a licensed nurse will report to physician/advanced practice provider (APP). Review of facility provided document, titled After Hour, Weekend and Holiday Calls to Physicians/Advanced Practice Provider Process Guidelines, dated May 30,…

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

Based on observations, facility policy review, and staff interview, it was determined that the facility failed to ensure that care and services were provided in a manner which promoted resident dignity in one of four dining areas (Station 3 Dining Room). Findings include: Review of facility policy, titled Resident Rights Under Federal Law, revised February 1, 2023, revealed, The resident has a right to be treated with respect and dignity. Observation in the Station 3 Dining Room on October 21, 2024, at 12:03 PM, revealed Employee 8 (Nurse Aide) standing while feeding Resident 115 several bites of food. Observation in the Station 3 Dining Room on October 22, 2024, at 12:16 PM, revealed Employee 10 (Nurse Aide) standing while feeding Resident 29; and observation at 12:21 PM, revealed Employee 9 (Nurse Aide) standing while feeding Resident 137. During an interview with the Director of Nursing on October 24, 2024, at 11:03 PM, she revealed the expectation that staff should be seated when assisting residents with eating. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code…

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

Based on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring for restraint use, including consent, physician orders, initial and ongoing evaluations, and scheduled removal, for one of one residents reviewed for restraints (Resident 126). Findings include: Review of facility policy, titled Restraints: Use of, revised June 15, 2022, revealed, When the use of restraints is indicated, the Center must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints .If the device cannot be easily removed by the patient and/or restricts freedom of movement or normal access to their body, the Restraint Evaluation/Reduction will be completed prior to the application of any restraint .Patients with a restraint will be re-assessed as follows or per state regulations: Monthly for three months, then quarterly, and with any significant change in condition .There must be documentation identifying the medical symptom being treated and an order for the use…

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, policy review, and staff interviews, it was determined that the facility failed to ensure that physician's orders were implemented for one of 35 residents reviewed (Resident 49); and failed to ensure assessments were completed for three of 36 residents reviewed (Residents 162, 228, and 522). Findings include: Review of the facility policy, titled Skin Integrity and Wound Management, last revised October 15, 2024, stated a comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin/wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. Review of facility policy, titled OPS118 Hospice, last reviewed July 2024, stated, in part, 8. For Center patients…

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 review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring for acceptable parameters of hydration and nutritional status for two of seven residents reviewed for nutrition or hydration (Residents 92 and 157); and failed to notify the physician of a significant weight loss for one of five residents reviewed for nutritional status (Resident 72). Findings include: Review of facility policy, titled Weights and Heights, revised February 1, 2023, revealed that significant weight changes will be reviewed by the licensed nurse for assessment. Significant weight change is defined as 5% in one month or 10% in six months. The licensed nurse will notify the physician and dietician of significant weight changes and document the notification in a progress note. The licensed nurse will notify the physician of the dietitian recommendations. Review of Resident 72's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory…

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 document review and staff interview, it was determined that the facility failed to complete a performance review of every nurse aide at least once every 12 months for five of five nurse aide documents reviewed (Employees 11, 12, 13, 14, and 15). Findings Include: A review of Employee 11's documents revealed a hire date of December 10, 2022. A continued review of Employee 11's information revealed no recent performance evaluation. A review of Employee 12's documents revealed a hire date of December 10, 2022. A continued review of Employee 12's information revealed no recent performance evaluation. A review of Employee 13's documents revealed a hire date of September 28, 2023. A continued review of Employee 13's information revealed no recent performance evaluation. A review of Employee 14's documents revealed a hire date of August 17, 2023. A continued review of Employee 14's information revealed no recent performance evaluation. A review of Employee 15's documents revealed a hire date of August 10, 2023. A continued review of Employee 15's information revealed no recent…

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

Based on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber for four or five residents reviewed for unnecessary medications (Residents 12, 15, 25, and 72). Findings Include: Review of facility policy, titled Section 1.3 Organization Aspects Consultant Pharmacist Services Provider Requirements, last reviewed July 2024, read, in part, Regular and reliable consultant pharmacist services are provided to residents. 4. The consultant pharmacist or designee, provides pharmaceutical care services, including but not limited to the following: .d. Medication Regimen Reviews (MRR) for each Skilled Nursing (SNF) resident at least monthly, or more frequently under certain conditions, incorporating the federally mandated standards of care in addition to other applicable professional standards. e. Communicate to the responsible prescriber, the facility's medical director and the director of…

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

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure adequate monitoring of psychotropic medications to ensure that resident were free from unnecessary medications for one of five residents reviewed for unnecessary medications (Resident 15). Findings include: Review of facility policy, titledAntipsychotic Medication Use, dated June 2022, revealed, Antipsychotic medications may be considered for elderly patients with dementia (those with behavioral or psychological symptoms) but ONLY after medical, physical, functional, psychological, emotional, social and environmental causes have been evaluated/addressed. Antipsychotic medications must be prescribed at the lowest possible dosage, for the shortest period of time. Review of Resident 15's clinical record revealed diagnoses that included dementia with behavioral disturbance (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and major depressive disorder (mental disorder characterized by at…

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

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen and four of four pantry areas. Findings include: Review of facility policy, titled Refrigerated/Frozen Storage, dated May 1, 2023, read, in part, Food stored under refrigeration/freezer storage is maintained in a safe and sanitary matter. All foods are labeled with the name of the product and the date received and 'use by' dates are used until opened. Prepared foods are labeled and dated with the name of the product, date opened, and 'use by' date. Food and Nutrition Services employees observe and record equipment temperatures daily according to the Refrigeration/Freezer Temperature Standards. Foods are kept in their original containers. If removed from the original container, foods are completely covered and labeled with the name of the product and 'use by' date. Observation of the dry storage area on October 21, 2024, at 9:54 AM, revealed one open bag…

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

Based on observations, facility policy review, and staff interviews, it was determined that the facility failed to ensure implementation of Enhanced Barrier Precautions to prevent the spread of infection by wearing required PPE (personal protective equipment) and hanging correct signage for six of 37 residents observed (Residents 2, 47, 58, 71, 91, and 159). Findings Include: Review of facility policy, titled Enhanced Barrier Precautions, revised January 8, 2024, revealed that enhanced barrier precautions are to be used to reduce the risk of epidemiologically important microorganisms by direct or indirect contact. Additionally, Enhanced Barrier Precautions is based on the Centers for Disease Control & Prevention (CDC) guidance. Further review of the policy failed to reveal any expectation that residents with indwelling medical devices should be placed on Enhanced Barrier Precautions. Review of CDC guidance, Review of Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated April 2, 2024, at cdc.gov…

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 employee file review and staff interview, it was determined that the facility failed to ensure the required nurse aide in-service training be no less than 12 hours per year and include dementia management training and resident abuse prevention training for three of five nurse aide documents reviewed (Employees 12, 13, and 15). Findings Include: A review of Resident 12's training information revealed a total of 6:13 hours documented and did not include the required dementia management or resident abuse prevention training. A review of Resident 13's training information revealed a total of 9:00 hours documented and did not include the required resident abuse prevention training. A review of Resident 15's training information revealed a total of 3:08 hours documented and did not include the required dementia management training. An interview with the Nursing Home Administrator on October 22, 2024, at 12:05 PM, revealed an acknowledgment of those nurse aides not having completed the required trainings and meeting the required 12 hours of training. 28 Pa. Code 201.19 (7)…

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

Based on observations and staff interview, it was determined that the facility failed to ensure a clean, comfortable, homelike environment, as evidenced by soiled wheelchairs, for three of 35 residents reviewed (Residents 53, 72, and 96). Findings include: Observation on October 21, 2024, at 10:13 AM and on October 22, 2024, at 9:35 AM, revealed an accumulation of crumbs, pieces of food, and other dried debris on the rails of Resident 53's wheelchair. Observation on October 21, 2024, at 12:10 PM, revealed an accumulation of dried smears and crumbs on the seat, wheels, and rails of Resident 96's wheelchair. Observation on October 23, 2024, at 12:07 PM, revealed an accumulation of dried food and crumbs on the seat, handle, and rails of Resident 72's wheelchair. During an interview with the Director of Nursing on October 24, 2024, at 11:04 AM, she acknowledged that the aforementioned wheelchairs needed to be cleaned. 28 Pa. Code 207.2(a) Administrator's responsibility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the resident and/or the resident's representative were provided the bed-hold notice upon transfer for two of five residents reviewed for hospitalizations (Residents 71 and 157). Findings include: Review of facility policy, titled Bed Hold Notice - Deliver Upon Transfer, last reviewed July 2024, stated, in part, Prior to a resident's transfer out of the center to a hospital or for therapeutic leave, the staff member conducting the transfer out will provide both the resident and representative, if applicable, with the bed hold policy notice and authorization form. Notice must be given regardless of payer. Review of Resident 71's clinical record revealed diagnoses that included injury of the cervical spinal cord (injury that affects the upper part of the spinal cord) and neuromuscular dysfunction of bladder (condition causing loss of bladder control). Further review of Resident 71'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, record review, observation, and staff interviews, it was determined that the facility failed ensure the resident received care, consistent with professional standards, to treat and prevent pressure ulcers for one of two residents reviewed with pressure injuries (Resident 91). Findings Include: Review of facility policy, titled Wound Dressings: Aseptic, Revised December 1, 2021, revealed in step 1. Verify order. Review of Resident 91's clinical record revealed diagnoses of pressure ulcer of left heel (localized area of damaged skin or tissue that occurs when pressure is applied to the skin for a prolonged period of time) and pressure ulcer of the left buttock (localized area of damaged skin or tissue that occurs when pressure is applied to the skin for a prolonged period of time). Review of Resident 91's current physician order on October 24, 2024, at 11:15 AM, revealed a physician's order to cleanse Resident 91's left ischium wound with Dakins (wound cleansing solution) every day and evening shift, then apply medihoney, finally apply Dakins soaked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records review, policy review, facility document review, and resident and staff interviews, it was determined that the facility failed to ensure that the medications ordered by the physician were available for one of 35 residents reviewed (Resident 229); and failed to provide documentation of disposition of medications for one of three closed records reviewed (Resident 170). Findings include: Review of facility policy, titled Disposal of Medication Waste, last revised October 24, 2022, read, in part, All medications will be disposed of in accordance with applicable federal, state, and local regulations for the disposal of chemical and potentially dangerous or hazardous pharmaceuticals. Medications for disposal include medications which are not taken with the patient upon discharge. Review of Resident 170's clinical record revealed diagnoses that included muscle weakness and hypertension (high blood pressure). Further review of Resident 170's clinical record revealed she was discharged from the…

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

Based on observations, facility policy review, and staff interviews, it was determined that the facility failed to place opened dates on medications in one of four medication carts (100 hall) and one of two medication storage rooms (Station 1) observed. Findings Include: Review of facility policy, titled Section 4.1 Storage of Medication, last reviewed July 2024, read, in part, Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. Procedures 12.Note the date on the label for insulin vials and pens when first used. Review of facility policy, titled Section 9.10 Appendix of Resources Medication with Shortened Expiration Dates, last reviewed July 2024, stated, in part, Tuberculin PPD .discard vials in use after 30 days. Observation made on October 24, 2024, at 10:07 AM, with Employee 21 present, of the medication cart in the 100-hall revealed, revealed one open insulin glargine pen with no open date, one open Humalog Kwik pen, one open Lantus insulin pen…

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

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of nine residents reviewed (Resident 2). Findings Include: Review of Resident 2's clinical record revealed diagnoses that included end stage renal disease (ESRD- when the kidneys no longer work as they should to meet the body's needs) and idiopathic pulmonary fibrosis (a condition in which the lungs become scarred and breathing becomes increasingly difficult). Review of Resident 2's clinical record revealed a progress note, written by Employee 1 (Licensed Practical Nurse [LPN]) on August 10, 2024, at 1:14 AM, stating that Resident 2 was anxious, diaphoretic (excessive sweating), and was stating that he was not getting oxygen from his nasal cannula. Review of Resident 2's blood pressures, documented by Employee 1, revealed that on August 10, 2024, at 12:47 AM, Resident 2's blood pressure was 82/42 (normal is 120/80) and on August 10, 2024, at 1:22 AM, Resident 2's blood pressure was…

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

Based on observation, review of facility policy, and staff interview it was determined that the facility failed to provide food and beverage that were at a safe and appetizing temperature for one of one meal observed on the short-stay rehabilitation unit. Findings include: Food and Nutrition Services Policies and Procedures Food service Quality Indicators Policy, revised May 1, 2023, read, in part, foods are served at temperatures appropriate for food safety and palatability. Review of the Food and Nutrition Services Test Tray evaluation form, revised May 1, 2023, documented that hot entrées, starches ,vegetables and hot beverages should be greater than 140 degrees Fahrenheit, milk should be at or below 45 degrees Fahrenheit, and cold beverages and desserts should be at or below 55 degrees Fahrenheit. Review of the Resident Council meeting minutes for January and February 2024, revealed ongoing concerns with the quality and the temperature of food during mealtimes. A test tray was completed on March 6, 2024, on the short-stay rehabilitation unit. Test tray temperatures were taken by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and staff interviews it was determined that the facility failed to provide pharmaceutical services to assure the accurate acquiring, receiving, dispensing, and administration of drugs to meet the needs of each resident for one of 6 residents reviewed (Resident 4). Findings include: Review of Resident 4's clinical record revealed diagnoses that included: Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), hypertension (high blood pressure), and depression (feelings of severe despondency and dejection). Further clinical record review revealed Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's physician orders, medication administration record and progress notes revealed the following medications weren't administered on the following dates and times: Carbidopa-Levodopa Oral Tablet 25-100 MG, 1 tablet by mouth four times a day (scheduled to be administered 7:30 AM, 11:30 AM, 4:30…

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 document review and staff interview, it was determined that the facility failed to ensure its Facility Assessment addresses the resources necessary to care for its residents, including staff competencies necessary to provide the level and types of care needed for its resident population, for one facility assessment reviewed (Dated November 16, 2023-December 7, 2023). Findings Include: The intent of the Facility Assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. Review of the information documented in the Facility Assessment revealed no information outlining the staff competencies necessary to care for the facility's resident population. An interview with the Nursing Home Administrator, on November 30, 2023, at 12:50 PM, revealed the Facility Assessment has not been completed correctly and will be reviewed for compliance ongoing. 28 Pa. Code 201.18 (b) (1) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and interviews with staff, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of 34 residents reviewed (Resident 60) and one of three dining rooms observed (The Bread Basket). Findings include: Review of the facility's policy, titled OPS213 Treatment: Considerate and Respectful, last reviewed on August 7, 2023, the policy stated under Process section 1.9 Demeaning practices: Staff will refrain from practices that are demeaning to patients such as: 1.9.1 Keeping urinary catheter bags covered. Review of Resident 60's clinical record revealed diagnoses that included hyperlipidemia (a condition in which there are high levels of fat particles in the blood) and aphasia (a language disorder that affects a person's ability to communicate). On November 27, 2023, at 1:49 PM, Resident 60 was observed sitting in her Broda chair in the hallway beside nursing station 3 with no dignity bag…

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, observation, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 34 residents reviewed (Residents 42, 98, 114, and 136); and failed to ensure the care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, for three of 34 residents reviewed (Residents 23, 81, and 103). Findings include: Review of Resident 23's clinical record revealed diagnoses that included osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of Resident 23's care conference summary dated November 3, 2023, revealed the only interdisciplinary team members involved were activities and social services. There was no evidence that nursing or a member of the food and nutrition services staff were…

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, clinical record review, and staff interviews, it was determined that the facility failed to provide routine assessments of pressure ulcers for two of four residents reviewed for pressure ulcers (Residents 98 and 114). Findings Include: Review of facility policy, titled Skin Integrity and Wound Management, revised February 2023, revealed, Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with unanticipated decline in wounds. Review of Resident 98's clinical record revealed diagnoses of muscle weakness (weakness of muscle movements) and diabetes mellitus (group of diseases that result in too much sugar in the blood [high blood glucose]). Review of a physician evaluation for Resident 98 from June 2, 2023, revealed that Resident 98 had a stage 4 pressure ulcer of the sacral region. Further review of Resident 98's nursing progress notes revealed a progress note from August 14, 2023, at 2:36 PM, that was an evaluation of Resident 98's sacral…

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 document review and staff interview, it was determined that the facility failed to complete a performance review for nurse aide staff at least once every 12 months for five of five employee files reviewed (Employees 7, 8, 9, 10, and 11). Findings Include: Review of Employee 7's personnel record revealed a hire date of September 8, 2008, and no evidence of a recent annual performance review. Review of Employee 8's personnel record revealed a hire date of April 27, 2018, and no evidence of a recent annual performance review. Review of Employee 9's personnel record revealed a hire date of October 6, 2008, and no evidence of a recent annual performance review. Review of Employee 10's personnel record revealed a hire date of July 22, 2015, and no evidence of a recent annual performance review. Review of Employee 11's personnel record revealed a hire date of October 19, 2009, and no evidence of a recent annual performance review. An interview with the Nursing Home Administrator on November 28, 2023, at 9:15 AM, revealed she could not locate any annual performance reviews 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.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure one of 34 residents reviewed were free of unnecessary psychotropic medications (Resident 25). Findings include: Review of Resident 25's clinical record revealed diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 25's clinical record revealed their current physician's orders to include and order for Haloperidol Oral Tablet (an antipsychotic which is a subcategory of psychotropic medication) 5 milligrams (mg) by mouth one time a day, with a start date of July 4, 2023, with the indication for the medication as psychosis. Review of Resident 25's clinical record also revealed on their current physician's orders, an order which included Abilify Oral Table (an antipsychotic which is a subcategory of psychotropic medication) 5 milligrams (mg) by mouth one time a day, with a start…

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

Based on observation, review of facility policy, and staff interview, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in one of four nourishment pantries (Station 4 nourishment pantry). Findings include: Review of 2021 International Plumbing Code (IPC) 802.3.1 Air Gap revealed, The air gap between the indirect waste pipe and the flood level rim of the waste receptor shall be not less than twice the effective opening of the indirect waste pipe. Observation in the Station 4 nourishment pantry on November 27, 2023, at 10:50 AM, revealed the wastewater drainpipe from the ice machine was extended into a funnel connected to the drain and there wasn't an air gap. Interview with the Nursing Home Administrator on November 30, 2023, at 12:15 PM, revealed that maintenance had removed the funnel from on top of the drain and cut back the drainage pipes of the ice machine in station 4 nourishment pantry to create an air gap, and that her expectation is that there would have been an air gap to prevent possible…

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, document review, and staff interviews, it was determined the facility failed to ensure coordination of necessary service for one out of two residents reviewed receiving Hospice services. (Resident 25) Findings include: Review of Resident 25's clinical record revealed diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 25's clinical record revealed that the Resident was receiving Hospice services related to a diagnosis of end stage Chronic heart failure following a physician order admitting the Resident to Memorial [NAME] Hospice, effective June 14, 2023. Review of a client coordination notes report from Memorial [NAME] Home Health and Hospice received on November 29, 2023, at 2:00 PM, revealed Resident 25 was discharged from hospice on November 7, 2023. During an interview…

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

Based on document review and staff interview, it was determined that the facility failed to ensure nurse aides complete annual training, including dementia management and resident abuse prevention, and all training hours be no less than 12 hours per year for four of five nurse aide files reviewed (Employees 7, 8, 9, and 11). Findings Include: Review of Employee 7's personnel file revealed no documentation of dementia management or resident abuse prevention training. The file also revealed Employee 7 did not receive the minimum 12 hours of required annual training. Review of Employee 8's personnel file revealed no documentation of dementia management or resident abuse prevention training. The file also revealed Employee 8 did not receive the minimum 12 hours of required annual training. Review of Employee 9's personnel file revealed no documentation of dementia management or resident abuse prevention training. The file also revealed Employee 9 did not receive the minimum 12 hours of required annual training. Review of Employee 11's personnel file revealed no documentation of dementia…

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

Based on clinical record review and staff interview, it was determined that the facility failed to notify the listed emergency contact person (Resident's Representative) of the transfer to the hospital for one of four residents reviewed for hospitalizations (Resident 136). Findings include: Review of Resident 136's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 136's nursing progress notes revealed that on August 29, 2023, Resident 136 went to an outside orthopedic appointment and was then sent to the hospital from that appointment. Review of Resident 136's clinical record, to include progress notes, revealed no documented evidence that Resident 136's Resident Representative was notified of the transfer to the hospital. During an interview with the Nursing Home Administrator and Director of Nursing on November 29, 2023, at 1:59 PM, they stated they would reach…

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

Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to post the required information of the Grievance Official for two of four identified areas (Station 4 nursing area and Station 2 lobby area) Findings include: Review of facility policy, titled OPS204 Grievance/Concern, last reviewed on July 19, 2023, revealed, The Administrator will serve as the Grievance Officer who is responsible for overseeing the grievance process . Also, A description of the procedure for voicing grievances/concerns will be on each unit in a prominent location and must include: .The contact information of the grievance official with whom a grievance can be filed, that is, their name, business address (mailing and email) and business phone number. Observation on November 29, 2023, at 10:03 AM, at Station 4 nursing area revealed the Grievance information posted included the previous Nursing Home Administrator's name and contact information. Observation on November 29, 2023, at approximately 10:05 AM, at Station 2 lobby area revealed the Grievance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to notify the Resident/Resident Representative and the Representative of the Office of the State Long-Term Care Ombudsman of resident transfers, in writing, to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman for two of 34 resident records reviewed (Residents 40 and 136). Findings include: Review of Resident 40's clinical record revealed diagnoses that included diabetes mellitus (group of diseases that result in too much sugar in the blood [high blood glucose]) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of nursing progress note dated June 24, 2023, revealed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Resident and/or Resident Representative received written notice of the facility bed-hold policy at the time of transfer for one of four residents reviewed for hospitalizations (Resident 136). Findings Include: Review of Resident 136's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 136's nursing progress notes revealed that on August 29, 2023, Resident 136 went to an outside orthopedic appointment and was then transferred to the hospital from that appointment. Resident 136 was admitted to the hospital on [DATE]. Review of Resident 136's clinical record revealed no evidence that Resident 136 and/or her Representative received written notice of the facility's bed-hold policy.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 34 residents reviewed (Resident 25). Findings Include: Review of Resident 25's clinical record revealed diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of a client coordination notes report from Memorial [NAME] Home Health and Hospice received on November 29, 2023, at 2:00 PM, revealed Resident 25 was discharged from hospice on November 7, 2023, and their last date of service was on November 3, 2023. Review of Resident 25's MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated November 16, 2023, revealed that Section O0110. Special…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, resident clinical records, and staff interviews, it was determined the facility failed to develop and implement a baseline care plan within 48 hours of the resident's admission that would include the instructions needed to provide effective and person-centered care of the resident and meet professional standards of quality of care for one of 34 residents reviewed (Resident 42). Findings include: Review of facility policy, titled Person Centered Care Plan, last reviewed October 24, 2022, revealed a baseline care plan must be developed within 48 hours of admission/readmission for each resident that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care. A comprehensive care plan must be developed by the Interdisciplinary Care Planning Team within seven days after the completion of the comprehensive assessment (Minimum Data Set (MDS) - a federally mandated process for clinical assessment of all residents…

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

Based on clinical record review, policy review, and staff interview, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that outlines resident goals for admission and desired outcomes for one of 34 resident records reviewed (Resident 25). Findings Include: Review of the facility's policy, titled OPS416 Person-Centered Care Plan, last reviewed and revised on October 24, 2022, reveals that care plans include measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. Review of Resident 25's clinical record revealed diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 25's MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated…

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

Based on clinical record review, document review, and resident and staff interviews, it was determined that the facility failed to provide services that meet professional standards of practice for three of 34 residents reviewed (Residents 25, 103, and 136). Findings include: Review of the facility's contracted job description for the Registered Dietician revealed the functions to include Work with the facility team as necessary to help provide best care to residents. The job description continued, Comprehensive Nutrition and Annual Assessment completion. Review of electronic mail correspondence, dated November 29, 2023, at 12:06 PM, between Employee 6 (Registered Dietician) and the Director of Nursing read, I assess all residents at a minimum quarterly . When assessing residents, I will speak directly to the resident via telephone or their [family member]. Review of Resident 25's clinical record revealed diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and major depressive disorder (a mood disorder that…

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

Based on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure residents receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being for one of 34 residents reviewed (Resident 114). Findings Include: Review of Resident 114's clinical record revealed diagnoses that included retention of urine (difficulty urinating and completely emptying the bladder) and Stage 3 pressure ulcer to the sacrum (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device; stage 3 is full-thickness skin loss; sacrum-a triangular bone located at the base of the spine). Review of Resident 114's current care plan revealed an intervention, dated November 10, 2023, to encourage the Resident to get out of bed to their wheelchair three times per week. Observation of Resident 114 on November 27, 2023, at 10:20 AM, revealed Resident 114 in bed. Observation of Resident 114 on November 28, 2023, at 11:08…

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

Based on observation, staff interviews, and record review, it was determined that the facility failed to provide appropriate urinary catheter (tubing inserted into the bladder or suprapubic area to drain urine into a bag) care for one of 34 residents reviewed (Residents 49 and 114). Findings include: Review of Resident 49's clinical record on November 28, 2023, revealed Resident 1 had diagnoses that included obstructive uropathy (obstructed urinary flow), suprapubic catheter insertion (inserted through a small cut in the abdomen above the pubic bone) into the bladder, and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). Physician orders dated November 2023, identified that Resident 49 has an indwelling urinary catheter in place with a 16 French catheter and 10 milliliter filled balloon to maintain placement. Observation of Resident 49 on November 28, 2023, at 10:06 AM, revealed Resident 49's catheter tubing dangling on the top of his foot, but when he turned his wheelchair, the tubing would touch the wheel of his wheelchair. 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 clinical record review, facility policy review, and staff interview, it was determined that the facility failed to act on a pharmacy recommendation in a timely way, and failed to ensure that the physician documented a rationale for declination of a pharmacy review recommendation for one of 34 residents reviewed (Resident 25). Findings include: Review of the facility policy, titled Medication Regimen Reviews (MRR), last reviewed March 3, 2020, revealed, Facility should encourage Physician/Prescriber or other responsible parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR. For those issues that require Physician/Prescriber intervention, facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. The policy also revealed that The attending physician should address the consultant pharmacist's recommendation no later than their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 29 residents reviewed (Resident 40). Findings Include: Review of Resident 40's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (A group of lung diseases that block airflow and make it difficult to breathe) and Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar). Review of Resident 40's Annual MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated October 14, 2022, revealed that Section O0100c, Oxygen was marked NO, signifying that Resident 40 did not receive supplemental oxygen during the 14-day look-back period. Review of Resident 40's Quarterly MDS dated [DATE], revealed that Section O0100c, Oxygen was marked NO, signifying that Resident 40 did not receive…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident care plan was reviewed and revised to reflect the resident's current status for two of 30 residents reviewed (Residents 29 and 107). Findings include Review of Resident 29's clinical record revealed diagnoses that included hemiplegia affecting right side (inability to move, severe weakness, or rigid movement on one side of the body) and cerebral infarction (area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain). Review of Resident 29's current plan of care revealed an active focus area related to the presence of an IV insertion site (intravenous - a procedure where a needle is inserted directly into a vein to deliver liquids to the blood stream.) Review of Resident 29's August 2022 MAR (electronic form used to document physician orders as well as when and how medications are administered to a resident) showed an order for Ampicillin-Sulbactam Sodium Solution (antibiotic)…

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.