Grandview Nursing And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview, it was determined the facility failed to provide required adaptive dining equipment to maintain the resident's ability to eat independently for one resident out of 33 residents reviewed (Resident 188).Findings include: A review of the clinical record revealed Resident 188 was admitted to the facility on [DATE], with diagnosis to include muscle weakness and need for assistance with personal care. Review of the resident's comprehensive care plan, dated April 3, 2026, identified activities of daily living deficits related to weakness, dizziness, vertigo (type of dizziness) and impaired ambulation. Interventions included the use of weighted utensils (adaptive eating tools designed with extra weight to help stabilize hands, reduce tremors, and decrease spills during meals), and a two-handled cup for all meals to support safe and effective eating. Review of physician orders dated April 3, 2026, confirmed the resident was to receive weighted utensils…

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, staff interviews, and review of facility job descriptions, it was determined the facility failed to ensure staff responsible for participation in the Minimum Data Set (MDS, a federally mandated standardized assessment used to evaluate a resident's condition and guide care planning) assessment process were adequately trained and competent to perform assigned duties in accordance with federal requirements and professional standards of practice which resulted in inaccurate resident assessments for six out of eight residents reviewed (Residents 2, 4, 6, 7, 14, and 39). Findings include: A review of the facility job description titled MDS Coordinator Registered Nurse (RN) revealed the position is responsible for conducting and coordinating the development and completion of the resident assessment process in accordance with the requirements of federal and state regulations as well as company policy and procedure. Duties and responsibilities of the position include developing and monitoring a system to verify that all interdisciplinary team members have…

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

Based on review of select facility policy, resident grievance forms, and resident and staff interviews, it was determined that the facility failed to make prompt and adequate efforts to resolve ongoing resident complaints regarding delayed call bell response times expressed during interviews, including those voiced by four of four residents interviewed. (Residents 1,3,4 and 5).Findings include: A review of a facility policy titled Grievance Policy, last reviewed in January 2025, revealed it is the policy of the facility to ensure each resident has the ability to communicate grievances/concerns to appropriate facility staff for proper and timely follow up according to regulation and resident rights.A review of a quarterly Minimum Data Set assessment for Resident 5 (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 12, 2025 revealed a BIMS score of 14 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 13 to 15…

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

Based on observation, resident and staff interviews, and review of the facility's meal service schedule, it was determined that the facility failed to consistently maintain sufficient staffing in the dietary department to effectively and efficiently carry out the functions of the food and nutrition service department. This failure resulted in delayed meal service and meals not served at palatable temperatures for residents on the East unit.Findings include:A review of resident interviews conducted on December 4, 2025, revealed multiple concerns about the timeliness and palatability (how acceptable food is to eat based on taste, smell, texture and serving temperature) of meals. Resident 8, interviewed at 10:15 AM, reported meals were often late by an hour or more and served cold and unpalatable.Resident 9, interviewed at 10:35 AM, stated that over the last several weeks, meals, especially dinner, were generally thirty minutes or more past the scheduled time and were ice cold and unpalatable. The resident's visitor reported bringing food from the minimart at times out of concern 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.

Based on observations, resident and staff interview, and test tray results, and food committee minutes, it was determined that the facility failed to serve meals that were palatable, attractive, and at safe and appetizing temperatures for a test tray completed on East Unit during the lunch room tray service.Findings included: According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. A review of a facility evaluation form titled Meal Evaluation Form -Temperatures revealed that hot food items were assessed based on being greater than or equal to 120 degrees Fahrenheit and on palatability. Palatable means acceptable to taste, including appropriate temperature, texture, and flavor. A review of the facility's Menu Committee meeting minutes dated November 5, 2025, indicated residents reported that food was being served cold. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of select facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to assess and determine a resident's capability to self-administer medications for one of 13 residents reviewed (Resident 1).Findings include: A review of the facility policy titled Self-Administration of Medications, last reviewed September 2025, revealed that residents have the right to self-administer medications if the interdisciplinary team determines it is clinically appropriate and safe. The policy required:Residents who express the desire to self-administer medications will be assessed to determine ability to self-administer medications.In addition to the general evaluation of a resident's decision-making capacity, the nursing staff will perform a more specific skill assessment, including (but not limited to) the resident'sability to read and understand medication labels.The comprehension of the purpose and proper dosage and administration time for his…

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, and staff interviews, it was determined that the facility failed to notify the attending physician of a significant change in condition for one of nine residents reviewed (Resident CR1). This failure resulted in a delay in physician notification following a documented decline in the resident ' s physical and mental condition.Findings include:Review of the facility policy titled Acute Changes in Condition: Policy/Clinical Protocol last reviewed by the facility on January 23, 2025, revealed the facility shall identify a sudden, significant deterioration in the resident's baseline health status including identifying potential changes, reporting the changes, conducting a thorough assessment, implementing necessary interventions and communicating with the resident, family and healthcare providers, with the goal of addressing the change promptly and monitoring to prevent further complications. The facility shall manage acute changes in condition, and notify the…

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

Based on a review of clinical records, select facility policy, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan that reflected individualized fall-prevention interventions for one of ten sampled residents (Resident 2). Findings include: A review of the clinical record revealed Resident 2 was admitted to the facility September 22, 2022, with diagnoses including dementia (a condition characterized by a progressive loss of cognitive function including memory, intellectual ability, and decision making).A quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 19, 2025, documented Resident 2 demonstrated fluctuating attention and focus, and was easily distractible Resident 2 had a BIMS score of 00 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information). A BIMs score of 00 indicates severe cognitive impairment,…

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 clinical records, facility policy, and staff interviews, it was determined that the facility failed to implement planned interventions and provide necessary treatment and services to prevent the worsening of a pressure ulcer for one resident out of four residents reviewed for pressure ulcer care (Resident CR1).Findings include:According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk.The American College of Physicians (ACP) is a national organization of internists who specialize in the diagnosis, treatment, and care of adults. Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer…

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 clinical records, select facility policy, and staff interviews, it was determined that the facility failed to implement procedures to ensure the timely acquisition and administration of prescribed medications for one of twelve sampled residents (Resident CR2).Findings include: A review of the facility policy titled Administering Medications, last reviewed January 23, 2025, revealed medications should be administered in a safe and timely manner, and as prescribed. Further review revealed that mediations must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meals). A review of the clinical record revealed that Resident CR2 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder (a mental health condition that causes unusual shifts in mood, energy, and activity levels) and major depressive disorder (a mental health condition characterized by persistent low mood, lack of energy, poor concentration,…

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 of the dietary department, Pavilion unit dining room, and resident pantry areas, review of relevant facility policy, and staff interviews, it was determined the facility failed to maintain food service sanitation practices in accordance with acceptable professional standards for the safe preparation, handling, and service of food. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). During a tour of the facility kitchen on October 3, 2025, at 10:00 a.m., with the Corporate Dietary Manager, multiple sanitation…

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

Based on observation and staff interviews, it was determined that the facility failed to maintain a clean and sanitary environment in one of three resident care units (the [NAME] Resident Unit).Findings include: An environmental tour of the [NAME] Resident Unit was conducted on October 3, 2025.An observation of Room W-16 revealed a large amount of a white substance inside an incontinent brief (a disposable garment worn to manage urinary or fecal incontinence) that was strewn under and around Bed 3. The floor contained liquid stains, visible dirt, and paper debris. A fall mat (a cushioned floor pad placed beside a bed to minimize injury if a resident falls) was propped against the bathroom door frame. The fall mat was visibly soiled with dark liquid stains and dirt. Rooms W-9 and W-11 were observed to have dried liquid stains and dirt on the floors. At 9:30 AM, Resident 12 was observed seated in her wheelchair outside of the room. A brown liquid substance was noted on the resident's clothing, wheelchair seat, and wheelchair tires. Multiple large puddles of the same brown liquid 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.

Based on observations, a review of clinical records, select facility policies, documentation provided by the facility, and interviews with residents and staff, it was determined that the facility's administration failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental well-being of residents in the facility. Specifically, the administration failed to ensure resident safety when the facility's dietary department served a hazardous cleaning chemical to residents and failed to prevent ten out of fifty-seven residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) from ingesting the chemical. This deficient practice placed all fifty-seven residents residing in the East Wing at risk of consuming a hazardous cleaning substance and resulted in an immediate jeopardy to resident health and safety.Findings included:A review of the job description for the Nursing Home Administrator (NHA) dated June 3, 2024, revealed the administrator will lead and direct the overall operations of the facility. The NHA's essential duties 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 observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department.Findings include:Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).According to the United States Department of Agriculture (USDA), food that is mishandled can become contaminated with invisible, odorless, or tasteless pathogens. Proper storage practices…

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 provided documentation, clinical records, the facility's abuse prohibition policy, and staff interviews, it was determined the facility failed to conduct an investigation to rule out a reported allegation of misappropriation of a resident's finances and failed to report to the State Survey Agency within five working days of the incident, for one resident (Resident 104) out of 32 sampled residents. Findings include:A review of a facility entitled Abuse Prevention Program last reviewed by the facility on January 23, 2025, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. As part of the resident abuse prevention, the administration shall protect the residents from abuse by anyone including but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, or any other individuals. All reports of resident abuse,…

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 observation, a review of clinical records, and staff interviews, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included specific and individualized interventions to address a resident's need for oxygen therapy for one out of 32 residents sampled (Resident 1) and failed to address a resident's hydration needs for one resident out of 32 sampled (Resident 140).Findings include: A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that include chronic respiratory failure (a condition where the respiratory system is unable to remove carbon dioxide from or provide oxygen to the body), quadriplegia (a form of paralysis affecting all four limbs and the torso), and care related to a tracheostomy (a surgical procedure that creates an opening in the neck to access the trachea for breathing or to bypass an obstruction in the upper airway). A review of the physician’s order revealed Resident 1 was 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 a review of clinical records and staff interview, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure that licensed nurses followed physician orders for the administration of medications as prescribed to one resident of the 32 sampled residents (Resident 82).Findings include:A review of the facility policy titled Subcutaneous Injections last reviewed by the facility on January 23, 2025, indicated that in preparation of administering subcutaneous (under the skin) injections licensed nursing staff must verify there is a physician's medication order for the procedure. Staff are to verify the order for the resident's name, drug name, dose, time and route of administration.A clinical record review revealed that Resident 82 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus (a condition in which the body has difficulty controlling blood sugar and using it for energy) and long-term…

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, review of select facility policy, and staff interview, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility to the extent possible for one resident out of 32 residents sampled (Resident 8). Findings include:Findings include:A review of the facility policy titled Restorative Nursing Services, last reviewed on January 23, 2025, revealed that residents will receive restorative nursing care as needed to help promote optimal safety and independence. Further review of the policy revealed the resident's restorative goals and objectives are individualized and resident-centered and are outlined in the residents' plan of care. A review of the clinical record for Resident 8 revealed the resident was admitted to the facility on [DATE], with diagnoses to include Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, select facility policy, and resident and staff interviews, it was determined the facility failed to ensure the availability of necessary emergency supplies for one of three residents reviewed who received hemodialysis (Resident 70). Findings include:According to the National Kidney Foundation, patients receiving hemodialysis (a machine that filters waste, salts, and fluid from the blood when the kidneys are no longer healthy enough to do this work adequately) should have access to emergency care supplies, including at bedside, to promptly respond to complications such as bleeding from the dialysis access site. For residents with an arteriovenous (AV) fistula, a surgically created connection between an artery and a vein commonly used for dialysis access, rapid access to emergency supplies is critical, as complications such as ruptures or bleeds from the site can result in life-threatening blood loss.A review of the facility policy titled Hemodialysis Care, 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.

Based on review of select facility policy and controlled substance records, observation, and staff interview, it was determined the facility failed to implement established pharmacy procedures for the reconciliation of controlled substances on one of five medication carts reviewed (Pavilion cart #2).Findings include:A review of facility policy titled Controlled Substances last reviewed by the facility on January 23, 2025, indicated that nursing staff must count controlled medications (medications with high potential for abuse) at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.An observation of the Pavilion medication cart #2 on July 17, 2025, at 8:35 AM, revealed Employee 5 (Registered Nurse) actively working from the medication cart. A review of a document titled Change of Shift Controlled Medication Count Sheet, identified by Employee 5 as the change of shift controlled substance count sheet for July 2025, for the Pavilion cart #2,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of resident clinical records, select facility policy, facility investigative reports, and staff interviews, it was determined the facility failed to ensure that one of 32 residents reviewed was free of significant medication errors. (Resident 123).Findings include:A review of the facility policy titled Administering Medications, last reviewed on January 23, 2025, revealed that medications shall be administered in a safe and timely manner as prescribed and the individual administering medications must verify the resident's identity before giving the resident their medications. Methods of identifying the resident include checking their identification band, checking their photograph attached to the medical record, and, if necessary, verifying the resident identification with other facility personnel. Further review revealed the individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method 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 observation, a review of select facility policy, and staff interview, it was determined the facility failed to ensure that medications and pharmaceutical products were stored in accordance with expiration date guidelines in one of three medication storage areas (Pavilion medication storage room).Findings include:A review of the facility policy titled Storage of Medications last reviewed by the facility on January 23, 2025, indicated all medications will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with the Destruction of Unused Drugs Policy. An observation conducted on July 17, 2025, at 9:00…

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 select facility policy, clinical records, and staff interview, it was determined the facility failed to ensure the resident or resident's representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization for one of five residents reviewed. (Resident 47)A review of facility policy titled Pneumococcal Vaccine, last reviewed in January 2025, revealed it is the facility's policy that all residents shall be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Furthermore, the policy indicates residents and resident representatives have the right to refuse the vaccination. If refused, appropriate entries shall be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination.A clinical record review revealed Resident 47 was admitted to the facility on [DATE].A review of Resident 47's immunization tab section of the electronic health record revealed pneumovax dose…

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 clinical records, relevant facility policies, resident and staff interviews, and direct observations, it was determined the facility failed to follow its established policy and procedures related to safe smoking practices for one of 32 sampled residents (Resident 139).Findings include:Review of the facility policy titled Resident Smoking Policy last reviewed by the facility January 23, 2025, indicated that the facility shall assess residents to determine safe smoking practices while allowing them to smoke supervised or independently. Policy procedure included Smoking supplies for Supervised and Independent residents will be kept in the locked nursing medication room. Residents are not entitled to keep smoking supplies in their possession.A clinical record review revealed that Resident 139 was admitted to the facility on [DATE], with diagnoses to include quadriplegia (partial or complete paralysis of all four limbs and torso), and chronic obstructive pulmonary disease (lung disease 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 a review of clinical records, select facility investigative reports, select facility policy, and staff interviews, it was determined the facility failed to implement effective safety measures to mitigate fall risk for one out of 12 sampled residents (Resident 1). Findings include: A review of the facility's policy entitled Managing Falls and Fall Risk, last reviewed by the facility on January 23, 2025, revealed that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included generalized muscle weakness, difficulty in walking, and a history of falling. A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 1, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to develop and implement an individualized plan to meet the toileting needs of one of 12 sampled residents (Resident 2), including the timely provision of staff assistance with toileting and management of urinary and bowel incontinence. Findings include: A review of facility policy titled Urinary Incontinence - Clinical Protocol provided by the facility on May 28, 2025, revealed that, as appropriate, and based on assessment of the category and causes of incontinence, staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. The staff and physician will review the progress of individuals with impaired continence until continence is restored or improved as much as possible, or it is identified that further improvement is unlikely. A review of Resident 2's clinical record revealed she was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, review of facility policy, and test tray analysis, it was determined the facility failed to ensure that meals were served at palatable temperatures and in a manner that met resident preferences for 5 out of 9 residents interviewed (Residents 1,2,3,4 and 5), and for one of one test tray meals reviewed during lunch service on the East Unit. Findings included: According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, specifies that food temperatures between 41°F and 135°F allow rapid growth of pathogenic microorganisms that can cause foodborne illness. Hot foods must be maintained at or above 135°F and cold foods at or below 41°F. Review of the facility policy titled Food Temperatures last reviewed by the facility on January 23, 2025, indicated all hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135…

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 observation, resident and staff interviews, and review of facility policy, it was determined the facility failed to maintain a fully functioning resident call bell system that ensured direct and timely communication between residents and caregivers for three of nine residents sampled (Residents 4, 5, and 6). Findings include: A review of the facility policy titled Answering Call Bell last reviewed by the facility on January 23, 2025, revealed it is the responsibility of all staff to respond to call bells, as displayed on a scrolling [NAME] on each unit. The policy stated that nurse aides, charge nurses, and RN supervisors are required to carry a pager to receive notifications of activated call bells. Walkie-talkies are to be used to request assistance for two-person tasks. If a pager or call bell device is non-functioning, maintenance must be notified immediately, and residents are to be provided a handbell until the system is repaired. The policy also stated that Administration and the QA Committee…

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, a review of the facility's planned cycle menus, and resident and staff interview it was determined the facility failed follow written planned menus for four of four residents sampled for meals. (Residents 3, 6, 4 and 8). Findings included: Review of the facility policy titled Menu Substitutions last reviewed by the facility January 23, 2025, revealed that menu substitutions will be made after discussion with the director of food and nutrition services whenever possible. Kitchen staff will consult with the director of food and nutrition or designee on any needed menu substitution. All changes to the menu (including the date, menu item substitution, and reason for the substitution) will be recorded. The registered dietitian nutritionist (RDN) or designee will periodically evaluate menu changes and if needed, an appropriate plan of action will be made to correct any concerns. Records of menu substitutions should be retained for 12 months. At the time of the survey ending on February 26, 2025, the facility census was 156 residents. Review of the facility's Week 2…

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 select facility policy, test tray results, and resident and staff interviews, it was determined the facility failed to serve meals that were palatable and maintained at a safe and appetizing temperature for 3 out of 17 residents sampled (Residents 3, 4, and 5). Findings include: According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. Review of the facility policy titled Food Temperatures last reviewed by the facility on January 23, 2025, indicated all hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit. All cold food items must be stored and served at a temperature of 41 degrees Fahrenheit or below. Temperatures should be taken periodically to assure hot foods stay above 135 degrees Fahrenheit and cold…

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 interview, it was determined the facility failed to provide adaptive dining equipment as required and prescribed for two residents out of 8 sampled residents. (Residents 7 and 8). Findings include: A review of the clinical record revealed Resident 7 was admitted to the facility on [DATE], with diagnosis to include cerebral infarction (brain damage that results from a lack of blood to the brain) and dysphagia (difficulty swallowing food or liquid). Review of Resident 7's plan of care, revised on April 29, 2024, indicated the resident had a potential for dehydration and was at risk for malnutrition. Interventions included the use of adaptive equipment. More specifically, the resident was to utilize a two-handled adapted cup with a lid for beverages at all meals. A review of the physician's orders, dated June 30, 2024, confirmed the resident was to utilize a two-handled adapted cup with a lid for beverages at all meals. Observation of Resident 7's breakfast…

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 clinical records and staff interviews, it was determined the facility failed to ensure that residents who were dependent on staff for assistance with activities of daily living were consistently provided showers as planned to maintain adequate personal hygiene for two of 17 residents reviewed (Resident 1 and Resident 2). Findings include: A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include hypertension (blood pressure that is higher than normal) and atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal). A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 1 dated November 29, 2024, indicated the resident required substantial/maximal assistance for showering/bathing. The resident was severely cognitively impaired with a BIMS score of 00 (brief 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 observations and staff interviews, it was determined the facility failed to provide food that accommodated residents' allergies, and dietary orders for thickened liquids for two of 8 residents reviewed (Residents 7 and 9). Findings include: A review of Resident 7's breakfast meal ticket (a menu-based document that provides essential information about a resident's meal such as diet order, preferences, food allergies, dislikes, dining location, supplements, and adaptive equipment if required, and helps staff accurately prepare and serve meals to residents based on their individual needs and preferences) indicated the resident had an allergy to dairy/milk. Observation of the resident's breakfast meal on February 26, 2025, at 8:24 AM revealed that dietary staff placed a Yoplait original harvest peach yogurt cup on the resident's breakfast tray. Review of the manufacturer's ingredient list for Yoplait original harvest peach yogurt indicated it contains cultured Grade A low fat milk which is a dairy product. Further review of Resident 7's meal ticket also indicated the 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.

Deficiency Text Not Available

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of clinical records, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by five residents out of the nine residents sampled (Residents 1, 2, 3, 4, and 5). Findings include: A clinical record review revealed Resident 5 was admitted to the facility on [DATE], with diagnoses to include cerebral infarction (brain damage that results from a lack of blood supply). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 7, 2024, revealed that Resident 5 is cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new…

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.

Deficiency Text Not Available

Deficiency Text Not Available

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and resident and staff interviews, it was determined the facility failed to provide care and services in a manner respectful of each resident's personal dignity for one of nine residents observed (Resident 3). Findings include: A clinical record review revealed Resident 3 was admitted to the facility on [DATE], with diagnoses that include Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 14, 2024, revealed that Resident 3 is cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).…

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 resident representative interview, a clinical records review, and staff interviews, it was determined that the facility failed to develop and implement a safe discharge plan for one of the 11 residents reviewed (Resident CR1). Findings included: A clinical record review revealed Resident CR1 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function) and traumatic brain injury (a brain injury caused by a sudden, external force to the head). A review of a discharge Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 27, 2024, revealed that Resident CR1 is moderately cognitively impaired with a BIMS score of 08 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate…

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.

Deficiency Text Not Available

Deficiency Text Not Available

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement nursing practices for the administration of an intravenous medication via central venous catheter for one of 5 residents reviewed (Resident 1). Findings include: According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. (b) The LPN…

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 the facility failed to implement pharmacy procedures for medication administration and documentation for one of five residents sampled (Resident 1 ). Finding include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE] with diagnosis to include, bacterial meningitis (a very serious type of infection which can cause the tissues around the brain to swell, leading to long-term complications and even death) and was admitted to the facility with a PICC line (a peripherally inserted central catheter a long catheter introduced through a vein in the arm and passed through to the larger veins into the heart). A review of physician's orders dated October 2, 2024, revealed, Penicillin G Potassium in Dextrose (an antibiotic medication) Intravenous Solution 40000 UNIT/ML, use 100 ml intravenously every 4 hours for bacterial meningitis for 27 Days. A review of Resident 1's Medication Administration Record for October…

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 the facility failed to develop and implement a comprehensive person-centered care plan that included specific and individualized interventions to address the resident's needs for intravenous medication administration through a central venous line (PICC catheter) to ensure the safe delivery of antibiotic medications and the care of the line for one out 5 residents sampled. (Resident 1). Findings include: A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnosis to include, bacterial meningitis (a very serious type of infection that can cause the tissues around the brain to swell, leading to long-term complications and even death) and was admitted to the facility with a PICC line (a peripherally inserted central catheter a long catheter introduced through a vein in the arm and passed through to the larger veins into the heart). An admission Minimum Data Set Assessment (MDS - a…

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

Based on observation, resident and staff interviews and a review of meal service delivery schedule it was determined the facility failed to consistently maintain sufficient staffing in the dietary department to effectively and efficiently carry out the functions of the food and nutrition service department. Findings include: Interview with the food service director (FSD) on September 24, 2024, at 9:30 AM revealed she is also cooking on this date for the breakfast and lunch meals. The FSD noted the food and nutrition services department was attempting to hire additional staff. Interview with Resident 48, a cognitively intact resident, on Tuesday September 24, 2024, at 11:30 AM revealed the past Sunday she did not receive supper until 7:45 PM at night. Review of the facility's Food Cart Delivery Schedule revealed the last cart of lunch trays was expected to arrive on the [NAME] Nursing Unit at 12:30 PM. Observation of the [NAME] Nursing Unit lunch meal on September 24, 2024, revealed the last cart of lunch trays did not arrive until 1:00 PM (30 minute delay). Interview with 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.

Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the kitchen in one of three resident pantries (West Nursing Unit). Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observation during the initial tour of the kitchen in the presence of the foodservice director (FSD) on September 24, 2024, at 9:20 PM revealed four…

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 select facility policies, the facility's infection control log and staff interview, it was determined the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility. Findings included: A review of facility policy entitled Infection Prevention and Control Program last reviewed June 2024, indicated the facility must establish an infection prevention and control program under which it identifies, investigates, controls, and prevents infections in the facility. The policy indicated the facility must maintain a record of incidents and corrective actions related to infections. A review of the facility's infection control data revealed the facility's infection control program failed to reflect an operational system to monitor and investigate causes of infection and manner of spread. There was no evidence of a system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner. A review of facility infection control logs for September 2023…

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 and staff training records, as well as staff interviews, it was determined the facility failed to provide dementia management training for five of five employees (Employees 12, 13, 14, 15, and 16). Findings include: The facility's policy regarding abuse, last reviewed July 2024, revealed that staff were to receive training on abuse and dementia management. Review of the education records/personnel files of employees hired in the last four months, revealed the following: Employee 12 was hired on September 12, 2024. There was no documented evidence that Employee 12 received dementia management training. Employee 13 was hired on September 6, 2024. There was no documented evidence that Employee 13 received dementia management training. Employee 14 was hired on August 1, 2024. There was no documented evidence that Employee 14 received dementia management training. Employee 15 was hired on July 2, 2024. There was no documented evidence that Employee 15 received dementia management training. Employee 16 was hired on July 31, 2024. There was no…

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 select facility policy, and staff interview, it was determined the facility failed to ensure the necessary information for filing a grievance was posted and/or provided/available to residents or their representatives, and failed to make residents aware of the procedure for filing a concern/grievance, written or verbally, and the procedure to file an anonymous grievance as reported by five of five residents (Residents 111, 134, 60, 135, and 46) during a group meeting. Findings include: A review of the facility's policy entitled Grievance Policy (reviewed July 2024) indicated it is the facility's policy all grievances and complaints filed will be investigated and corrective actions will be taken to resolve the grievance. During a group interview conducted on September 25, 2024, at 10:30 AM with 5 alert and oriented residents, five of five residents in attendance (Residents 111, 134, 60, 135, and 46) stated they were unaware of how to file a grievance. The residents were unaware of any information posted in the facility regarding the grievance 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 a review of clinical records, facility staffing records, and resident and staff interviews it was determined the facility failed to efficiently deploy sufficient nursing staff to provide timely and quality care to each resident including 4 residents out of 30 sampled (Residents 101, 68, 60, and 135). Findings include: A review of the clinical record revealed that Resident 68 was admitted to the facility on [DATE], with diagnoses to include diabetes (body has trouble controlling blood sugar and using it for energy), muscle weakness, and need for assistance with personal care. A review of the quarterly minimum data set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 13, 2024, revealed the resident was cognitively intact, with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognitive function. A score of 13-15 indicates cognitively intact responses) and required staff assistance 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.

Based on observation, select facility policy review and staff interview, it was determined the facility failed to implement and adhere to procedures to ensure acceptable storage and use by dates for multi-dose medications on one of four medication carts and two of two medication storage rooms observed (West medication cart #3, [NAME] medication storage room, and East medication storage room). Findings include: A review of facility policy titled Administering Medications last reviewed by the facility June 2024, revealed the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-use container, the date opened shall be recorded on the container. A review of the manufacturer instructions for the storage of Lantus Insulin vials, Insulin Aspart vials, Insulin Lispro vials, and Fiasp vials (medications used to manage diabetes) revealed the vials should be stored in the refrigerator until ready for use. Once the insulin vials are taken out of the refrigerator for use, they may be used for up to 28 days and should discarded after 28…

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, a review of facility's planned menus, and resident and staff interview it was determined the facility failed to accommodate individual food preferences to the extent possible, to increase resident satisfaction with meals for residents which included 8 residents of 30 residents reviewed (Residents 48, 128, 101, 111, 134, 60, 135, and 46). Findings include: During an interview with Resident 48, a cognitively intact resident, on September 24, 2024, at 11:30 AM the resident stated many times milk or sugar are not provided with meals. Resident 48 also stated at times an alternate meal is not always available for the main entrée and the only choice is a peanut butter and jelly sandwich. Resident 48 stated this morning there was no juice available for breakfast. Review of a grievance filed by Resident 48 on August 23, 2024, revealed a concern there was no bacon for breakfast, no milk, and no sugar. The response to the grievance included that sugar packets were ordered and now available. The response noted gallons of bulk milk were available at the time however, there…

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 the Menu Committee Minutes and resident and staff interviews, it was determined the facility failed to ensure that residents' drink preferences were honored for 7 of seven residents reviewed (Residents 48, 101, 111, 134, 60, 135, and 46). Findings include: Review of Menu Committee Minutes dated, May 1, 2024, revealed that 37 residents were in attendance. During the meeting the residents in attendance were informed that soda will no longer be available unless a resident has an upset stomach. Ginger Ale will be offered in that occurrence. Residents were informed the break room vending machines offer soda (no price provided). Also, BINGO prizes at times consist of soda. During an interview on September 24, 2024, at 11:30AM with Resident 48, a cognitively intact resident, revealed she was upset the facility was no longer offering soda. Resident 48 stated the vending machine price was too high. Resident stated her family has been providing her with soda since the facility had stopped providing soda as a beverage choice. During a group interview conducted on September…

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 observation, and staff interviews, it was determined the facility failed to consistently provide a fully functioning call system to provide direct communication from the resident to the caregivers for three of 3 nursing units. Observations on the Pavilion Nursing Unit on September 26, 2024, at 11:30 AM revealed when call bells are activated resident room numbers will scroll across a [NAME]. Staff assigned to care for residents must have a pager in their possession which is audible. Further observations revealed there were no pagers on the unit behind the nursing station for employees. An interview with Employee 5 RN (registered nurse) on September 26, 2024, at approximately 11:35 AM revealed she did not have a required pager on her to be alerted to the residents' call bells. An interview with Employee 6 NA (nurse aide) on September 26, 2024, at 11:37 AM revealed the employee did not have a pager to be alerted to the residents' call bells. An interview with Employee 7 LPN (license practical nurse) 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 clinical record review and staff interview it was determined the facility failed to include, in the resident's baseline plan of care, minimum standards of care to fully address the resident's immediate needs upon admission for one resident out 30 sampled (Resident 300) Findings: A review of Resident 300's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (a condition that occurs when the kidneys stop functioning) and dependence on renal dialysis (a treatment that removes excess water, waste products, and toxins from the blood when the kidneys are no longer able to function properly). A review of physician's orders revealed an order initially dated September 17, 2024, for the resident to receive dialysis on Tuesdays, Thursdays, and Saturdays at 5:30 AM. Review of Resident 300's baseline care plan failed to identify the resident is dependent on renal dialysis, three times per week. Additionally, the care plan failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interviews it was determined the facility failed to develop and implement an individualized discharge plan for one of 30 residents reviewed (Resident 134) to reflect the resident's discharge goals. Findings Include: Clinical record review revealed that Resident 134 was admitted to the facility on [DATE], with diagnoses to include alcohol abuse. Review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated August 31, 2024, indicated the resident had a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 9 indicating moderate cognitive impairment. The resident was independent with all activities of daily living. During an interview with Resident 134 on September 25, 2024, he indicated he does not want to be in the facility. When asked if social services was assisting him with a potential discharge to the community, 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 observation, review of clinical records, and resident and staff interviews it was determined that the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for bowel protocol for one resident (Resident 68) to promote normal bowel activity to the extent practicable and failed to follow physician orders for the consistent application of a prescribed therapeutic measures, wheelchair leg rests, for one resident of 30 sampled (Resident 136). Findings include: According to the American Academy of Family Physicians (The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine) the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week. A review of the facility policy titled Bowel Protocol last reviewed by the facility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 30 residents reviewed (Resident 137). Findings include: A review of the clinical record revealed that Resident 137 was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event). The resident's current care plan, in effect at the time of review on September 27, 2024, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. 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 clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one resident (Resident 38) out of 30 residents sampled. Findings include: A review of the clinical record revealed that Resident 38 was admitted to the facility on [DATE], with diagnoses to include dementia (a chronic condition that causes a loss of cognitive function, such as thinking, remembering, and reasoning, that interferes with daily life) with psychotic disturbances (severe mental disorder that cause abnormal thinking and perceptions). An admission MDS Assessment (Minimum Data Set - a federally mandated standardized assessment completed periodically to plan resident care) dated August 17, 2024, revealed the resident was severely cognitively impaired. A review of a nursing progress note dated August 30, 2024, at 9:46 AM revealed the resident was noted to be screaming and yelling out.…

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 the facility failed to show adequate monitoring of behaviors and potential adverse consequences of psychoactive medication and failed to consistently attempt non-pharmacological interventions prior to the administration of psychoactive drugs for one resident out of 30 residents reviewed (Resident 126). Findings include: Review of Resident 126's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included anxiety, adjustment disorder (a group of symptoms, such as stress, anxiety, feeling sad or hopeless, and physical symptoms that can occur after you go through a stressful life event), and non-traumatic subarachnoid hemorrhage (bleeding in the brain that occurs without head trauma). A review of physician orders revealed the resident had the following orders for Ativan (psychotropic antianxiety medication) : August 6, 2024, Ativan 0.5mg give 1 tablet by mouth every eight hours as needed for anxiety…

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

Based on review of clinical records and staff interview, it was determined the facility failed to offer routine annual dental services for one Medicaid payor source out of four residents sampled (Resident 77) for dental services. Findings include: Review of the clinical record of Resident 77 revealed admission to the facility on February 9, 2021, and the resident's payor source was Medicaid. There was no documented evidence at the time of the survey ending September 27, 2024, the resident had been offered dental services in the past year. Interview with the Director of Nursing on September 27, 2024, at approximately 9:30 AM confirmed the facility had not offered Resident 77 routine dental services in the past year. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment. Findings include: An observation on July 25, 2024, at 10:55 AM revealed the shower room on the pavilion nursing unit had a yellow liquid on the floor. A black mold like substance was noted on the caulking on the floor in the shower. The shower curtain was noted to have multiple dark spots, the caulking around the toilet was brown. There was multiple holes in the shower room door. Further observations on July 25, 2024, at 11:25 AM of the shower room in west nursing unit revealed a black mold substance in the shower on the caulking and on the shower curtain. Observations on July 25, 2024, at 1:20 PM revealed Room E4 was noted to have brown streaks and spots on the toilet. Debris was noted on the floor in the bathroom and bedroom area. There was large brown and black colored stains on the carpet in the bedroom. Food particles were noted on the floor mat. 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 clinical records, resident incident/accident reports, and staff interviews, it was determined that the facility failed to provide adequate staff supervision to monitor a resident to prevent an unsupervised exit from the facility for one resident (Resident 1) out of 10 reviewed. Findings included: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE]. The resident's diagnoses included traumatic subdural hemorrhage (brain bleed) and congestive heart failure. A review of Resident 1's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 24, 2024, revealed that the resident was severely cognitively impaired and had behaviors of wandering. A review of an Elopement Risk assessment dated [DATE], revealed the resident independently ambulates, was cognitively impaired, and has wandering behavior. The resident was considered at risk for elopement. A review of the…

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

Based on a review of select facility policy and clinical records and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses timely administered residents' medications as scheduled for two of 15 reviewed (Resident 2 and 8). Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing…

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

Based on review of clinical records and select facility policy and staff interview, it was determined that the facility failed to timely consult with the physician regarding significant changes in resident condition after a fall with injury, which precipitated an additional fall for one resident out of 15 sampled (Resident 4). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. A review of facility policy entitled Notification…

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 select facility policy and clinical records and staff interview it was determined the facility failed to maintain accurate and complete clinical records, according to professional standards of practice, by failing to record a registered nurse's assessment and communication with other members of interdisciplinary team for one resident out of 15 sampled (Resident 15). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the…

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

Based on observation, review of controlled drug shift count records and staff interview, it was determined that the facility failed to implement pharmacy procedures for the reconciliation of controlled drugs on nine of nine medication carts (Pavilion 1, 2, 3, East 1, 2, 3, and [NAME] 1, 2, 3). Finding include: A review of an untitled document, identified by Employee 7 Licensed Practical Nurse (LPN), as the change of shift controlled count sheet for April 2024, for the East medication cart # 1 on April 10, 2024, at approximately 8:40 AM, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify completion of the task to count the controlled drugs in the respective medication cart April 6, and 7, 2024. Interview with Employee 7 (LPN), on April 10, 2024, at approximately 8:42 AM, confirmed the observation and acknowledged the licensed nurse are expected sign the count verification at change of shift. A review of an untitled document, identified by Employee 8 (LPN), as the change of shift controlled count sheet…

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

Based on observation and staff interview and review of select facility policies, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review of the facility policy entitled Date Marking for Food Safety dated March 24, 2024 which indicated The facility adheres to a date marking system to ensure the safety 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 clinical record review and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure that licensed and professional nursing staff conducted a timely, and thorough assessment of resident's injury for one resident out of 17 sampled (Resident A1). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where…

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 menu committee minutes, and staff, and resident interviews, it was determined the facility failed to ensure effective management and execution of the facility's food and nutrition department by failing to demonstrate necessary communication and timely coordination, among and between facility and corporate staff, to ensure that food and nutrition services meet each resident's daily nutritional and dietary needs and choices, and with consideration to the preferences of each resident, including Residents B4 and B5. Findings include: A review of the minutes from the facility's Menu Committee Meeting held on April 3, 2024, the facility informed residents that only pasteurized liquid and shelled eggs can be served in the facility. The minutes noted that there will no longer be fried eggs until pasteurized shelled eggs are purchased. According to the Center for Clinical Standards and Quality/Survey & Certification Group Survey and Certification Memo dated May 20, 2014 CMS provided interpretive guidance and Procedures for Sanitary Conditions, Preparation of Eggs 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.

Based on observation, clinical record review and staff and resident interview, it was determined the facility failed to to administer intravenous therapy in accordance with professional standards of practice for one of one reviewed resident receiving intravenous therapy. (Resident A2) Findings include: A review of the clinical record revealed Resident A2 was admitted to he facility on March 8, 2024, with diagnoses of diabetes mellitus, wound infection, and high blood pressure. The resident had current physician orders initially dated March 10, 2024, for Vancomycin HCL (an antibiotic) intravenous solutions 1250 mg/250 ml, one time a day for osteomyelitis until April 15, 2024. During an interview with Resident A2 conducted on April 10, 2024 at approximately 10:54 AM the resident, who was alert and oriented, the resident was in his room, seated in a wheelchair. Resident A2 stated that last Friday (April 5, 2024), during the day shift, his IV Vancomycin was infused quickly via his PICC (peripherally inserted central catheter, a long catheter introduced through a vein in the arm, then…

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 observation and staff and resident interview it was determined the facility failed to ensure that each resident received food prepared by methods that conserve flavor and appearance for one resident out of 17 sampled (Resident B1). Findings included: Clinical record review revealed that Resident B1 was admitted to the facility on [DATE], with a fracture of her right femur. During an observation of the refrigerator in the facility's Pavilion Unit, on April 10, 2024 at 9:00 AM, a breakfast tray containing an omelette, apple juice, fruit cup and a carton of milk was observed. The meal ticket on this tray had the name of Resident B1, for a gluten free renal diet, and written on the ticket in blue marker was save tray. During an interview at the time of the observation with Employee 12, a Registered Nurse, she stated that the resident was out at an appointment. When asked when the resident was expected to return, Employee 12 stated the tray should not be kept until the resident's return, and disposed of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the facility's planned written menus, menu extensions, and select facility policy, and staff interviews, it was determined that the facility failed to follow planned menus, failed to ensure that the facility's dietitian periodically updated the planned menus to reflect variety, the preferences of the current resident population and nutritional adequacy and failed to assure consistent availability of food to serve the emergency menu in the event of an emergency. Findings included: A review of the current facility census at the time of the survey on March 12, 2024, revealed 165 residents were currently residing in the facility. Review of the facility's Week 3 lunch menu for Tuesday March 12, 2024, revealed that the planned menu included breaded baked fish, rice pilaf, buttered carrots, broth, and red white and blue poke cake. However, the observation of the lunch meal on March 12, 2024, at 12:00 PM revealed that unbreaded [NAME] (fish filet) was served in place of the breaded baked…

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 interview and a review of CMS guidelines, it was determined that the facility failed to maintain acceptable practices for the storage, preparation, and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness on the Pavilion Unit Resident Pantry and [NAME] Nursing Care Unit (two of three resident units) and the facility's kitchen and in the service of unpasteurized eggs to residents. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related 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 observation, resident and staff interviews and a review of select facility policy, it was determined the facility failed to consistently provide a fully functioning call system to maintain direct communication from the resident to the caregivers for six of 22 residents sampled (Residents A1, A2, A3, A4, A5, and A6) Findings include: A review of facility protocol regarding Call Light Response/Purposeful Rounding Expectations dated February 16, 2024, indicated the following: All call bells must be answered in a timely manner. 15 minutes or less is the facilities. Goal as expressed by the Resident Council in order to promote quality of life to the residents. All facility staff are responsible to answer call bells. Anyone out on the unit walking by a room can stick their head and ask what the resident needs. Social service activities, dietary maintenance, office staff etc. Do not turn off a call bell until the resident's need is being met. This means the call bell cannot be turned off and staff say they…

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 observation and staff and resident interview it was determined that the facility failed to ensure that each resident received food prepared by methods that conserve flavor and appearance for one resident out of 22 sampled (Resident B2). Findings included: Clinical record review revealed that Resident B2 was admitted to the facility on [DATE] with diagnosis to include diabetes. The resident was receiveing dialysis treatments and had a current physician order, dated May 23, 2023, for a renal diet. A review of the resident's current care plan in effect at the time of the survey revealed that the resident attends dialysis treatments on Tuesdays, Thursdays and Saturdays, leaving the facility at 5:30 AM During an observation of the refrigerator in the facility's dietary department, on March 12, 2024 at 9:15 AM revealed a breakfast tray containing scrambled eggs, apple sauce and apple juice. During an interview at the time of the observation, the CDM (certified dietary manager) stated that Resident B2 leaves…

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 clinical records and medication error reports and staff interview, it was determined that the facility failed to timely notify the resident's interested representative of a fall for one out of 22 residents sampled (Resident B1). Findings include: A review of Resident B1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include, osteoarthritis, spinal chronic kidney disease, dementia and a history of falling. A facility investigation report and nursing documentation dated January 1, 2024, at 1:41 PM revealed that staff found Resident B1 on the floor in her room, between her bed and the wheelchair, after the resident attempted to self transfer. Nursing noted that the resident sustained no apparent injury, denied discomfort and was able to move all extremities without discomfort. It was noted that the resident's non-skid socks had been applied incorrectly. Staff reapplied the socks. The resident was referred to therapy for evaluation 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 a review of clinical records, select incident reports and the facility's abuse prohibition policy it was determined that the facility failed to thoroughly investigate an injury of unknown source to rule out abuse, neglect or mistreatment as a potential cause of the injury presented by one resident out of 22 sampled (Resident B1). Findings include: Resident B1 was admitted to the facility on [DATE], with diagnoses of chronic kidney disease, osteoarthritis (when cartilage of the joint is worn down) of right shoulder, unsteadiness on feet, unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) without behaviors and psychotic mood disturbance (conditions that affect the mind, where there has been some loss of contact with reality). A review of a quarterly MDS (minimum data set- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 9, 2024, indicated the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff and family interview, it was determined that the facility failed to consistently monitor resident weights to timely identify and act upon a resident's weight loss, and implement necessary nutritional support to promote acceptable nutritional parameters for one resident out of 22 sampled (Resident B1). Findings include: A review of Resident B1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include, osteoarthritis, spinal chronic kidney disease, dementia and a history of falling. The resident was cognitively intact with a BIMS score of 14 (brief interview for mental status - a tool to assess cognitive function, a score of 13 to 15 indicates the resident is cognitively intact) according a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 23, 2023. The resident required the assistance of staff for activities…

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, select facility policy and reports, and staff and family interviews it was determined that the facility failed to timely evaluate increased pain and evaluate potential underlying causes and potential etiology for one resident out of 22 sampled (Resident B1). Findings include: A review of the facility policy for pain assessment and management reviewed January 2024 revealed that the purpose of this procedure is to help the staff identify pain in the resident, and to develop interventions that are consistanet with the resident's goals and needs and that address the underlying causes of pain. Pain management is a multidisciplinary care process that includes the following: assessing the potential for pain; effectively recognizing the presence of pain; identifying the characteristics of pain; addressing the underlying causes of pain; developing and implementing approaches to pain management; identifying and using specific strategies for different levels and sources of pain;…

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 the facility failed to provide therapeutic social services to promote the highest practicable mental and psychosocial well-being of one of the 22 residents reviewed (Residents A7). Findings include: A review of the clinical record of Resident A7 revealed admission to the facility on March 4, 2024, with diagnoses of cancer of the face and neck, for which the resident was receiving radiation treatments, a tracheostomy tube due to tracheostomy (a surgical procedure where a surgeon creates a hole through the neck and into the windpipe in order to deliver oxygen to the lungs safely. A tracheostomy tube is placed into the windpipe to deliver oxygen), adjustment disorder with depressed mood and history of substance abuse with opioid dependency. During an interview with a facility staff member, who did not wish to be identified for fear of retaliation, on March 12, 2024, at approximately 10 AM the employee stated that Resident A7 had expressed thoughts of wanting to kill himself. The resident reportedly made this…

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 nursing staffing, grievances filed with the facility, the facility assessment, clinical records and resident and staff interviews it was determined that the facility failed to provide sufficient nursing staff to consistently provide timely quality of care and services to maintain the physical and mental well-being of the residents including experiences described by eight residents (C1, C2, C3, A1, B1, B2, B3 and B4), grievances filed by four residents (Residents C4, C5, C6, and C7) and the delay or lack of care experienced by two residents (Resident 54 and CR1) out of 23 sampled residents. Findings include: Review of the facility assessment last reviewed by the facility [DATE], revealed that the facility had 172 resident beds and an average daily census was 157 to 165 residents. The general staffing plan to ensure sufficient staff to meet the needs of the residents at any given time (based on resident acuity) included 1 RN Supervisor 3:00 PM to 7:00 AM and weekend 24 hours; 1 licensed nurse…

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

Based on clinical record review and facility documentation and staff interview, it was determined that the facility failed to implement efficient pharmacy procedures for timely acquiring resident medications to ensure physician-ordered medications were readily available in a timely manner for one resident out of three sampled (Resident B1). Finding include: Review of Resident B1's clinical record revealed a physician order dated, January 27, 2024, for Oxycodone HCL (opioid pain medication) 5 mg one tablet by mouth every four hours for severe pain 4 to 10 for 3 days for a new diagnosis of fracture of left forearm and left shoulder. Review of Resident B1's January 2024 Medication Administration Record revealed that on January 27, 2024, at 11:09 AM Oxycodone HCL 5 mg was administered to the resident for a complaint of left arm pain. Review of information dated January 28, 2024, submitted by the facility revealed that on January 27, 2024, Employee 12 (LPN) took an Oxycodone IR (opioid pain medication) 5 mg from Resident CR2 PRN (as needed) narcotic card and gave it to Resident B1.…

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 the facility failed to provide person-centered care following a resident's injury by failing to demonstrate consistent monitoring and timely follow-up care required by one resident out of five sampled (Resident 54) Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings…

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

Based on observations and staff interviews, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment on one of the three facility nursing units (Nursing [NAME] Unit). Findings include: An observation on February 12, 2024, at 10:47 AM in resident room W-14 revealed yellow pieces of food debris and black-gray stains on the floor near the resident's window, two urine collection graduates on the floor in the resident's bathroom, and several brown stains on the window shades. An observation on February 12, 2024, at 10:50 AM in resident room W-17 revealed multiple stains and discolorations on the carpet, plastic clear candy wrappers on the floor, discoloration and stains on the floor carpet, and crumbs and food debris around and under a brown wooden dresser. An observation on February 12, 2024, at 10:53 AM revealed a black substance and discoloration on the floor between the resident rooms and in hallway between resident rooms W-17, W-18, and W-20. An observation on February 12, 2024, at 10:55 AM outside of resident room W-20…

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 clinical records, select facility policy, and facility incident reports, and resident, family and staff interviews, it was determined that the facility failed to thoroughly investigate allegations of abuse for two of the 23 residents sampled (Residents C9 and C10) and submit the results of the completed investigations to the State Survey Agency within five working days of the incident. Findings include: A review of facility policy titled Abuse Prevention dated January 27, 2024 revealed that physical abuse- includes hitting, slapping, punching, kicking. and verbal abuse- any use of oral, written, or gestured language that includes willfully disparaging and derogatory terms to residents or their families. The policy also indicates that allegations of abuse or neglect which are uncovered by investigation and tracking of incident reports will be investigated further and corrective actions taken according to the facility's abuse policies and procedures. A clinical record review revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy and reports, and employee job descriptions and staff interview it was determined the facility's administration failed to effectively use its resources to promote resident safety by failing to implement established procedures to provide cardiopulmonary resuscitation (CPR) in the event of cardiac arrest according to an resident's advanced directive for one out of three sampled residents (Resident CR1). Findings included: Review of the facility's policy and procedure titled Emergency Procedure - Cardiopulmonary Resuscitation last reviewed by the facility [DATE], revealed that if an individual (resident, visitor, staff) is found unresponsive and not breathing normally a licensed/certified staff member shall initiate CPR (Cardiopulmonary Resuscitation) unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and external defibrillation exist for that individual or there are obvious signs or irreversible death. According 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 a review of clinical records and facility documentation it was determined that the facility failed to provide nursing staff with the necessary competencies and skills to timely identify signs and symptoms of potential changes in resident condition and evaluating currently planned care regimens to timely respond to the residents' current needs for two residents out of five sampled (Residents 1 and 3). Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include diabetes, dysphagia (difficulty swallowing) mild intellectual disabilities and a history of falls. A quarterly MDS (Minimum Data Set-a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment, dated August 14, 2023, indicated that the resident was severely cognitively impaired with Brief Interview for Mental Status (BIMS) score was 4 and required extensive assistance with activities of daily living to include, bed…

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 clinical records and grievances lodged with the facility and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, as evidenced by experiences reported by four residents out of 17 sampled (Residents 1, 2, 3 and 22). Findings include: A clinical record review revealed that Resident 1 was admitted to the facility on [DATE]. According to the resident's Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 4, 2023, the resident is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool to assess cognitive function; a score of 13-15 indicates cognition is intact). During an interview on November 8, 2023, at 9:25 AM, Resident 1 stated that when he rings his call bell, it often takes staff about an hour…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of select facility policy, controlled drug records, and clinical records, and staff interview, it was determined that the facility failed to implement procedures to promote accurate controlled drug records and timely disposition of resident medications (the process of returning and/or destroying unused medications) to prevent waste. Finding include: Review of facility policy entitled, Disposition of Medications provided at the time of the survey ending [DATE], revealed that it establishes guidance regarding disposition of medications and to implement safe and responsible disposition practices of discontinued medications in order to protect residents and staff from improper diversion or accidental exposure. Further it is indicated medications discontinued by the prescriber order, residents' death, or discharge are either to be destroyed on site or return to the pharmacy for destruction. Controlled substances must be destroyed in the facility using the drug disposal system containing…

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

Based on review of clinical records, and staff interview, it was determined that the facility failed to timely consult with the physician regarding the potential need to alter treatment due to the resident's repeated refusal of a physician ordered medication, for one out of four residents sampled (Resident 22). Findings include: A review of Resident 22's clinical record revealed admission to the facility on October 27, 2023, with diagnoses of chronic obstructive pulmonary disease (COPD), osteoarthritis left knee, right hip, difficulty in walking, and dorsalgia (back pain). A review of current physician orders dated October 27, 2023, Lidoderm (Lidocaine) Patch 5 %, apply topically in the morning related to dorsalgia (back ache). An order administration note, dated November 7, 2023, at 1:50 PM revealed Lidoderm Patch 5 %, apply topically in the morning related to dorsalgia. Resident stated she does not need patch. The resident's October 2023 and November 2023 Medication Administration Record (MAR), indicated Lidoderm Patch 5 %, apply topically for dorsalgia, scheduled for 9:00 AM.…

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, a review of the facility's planned menus and resident and staff interview it was determined that the facility failed to provide preferred foods and beverages as planned for one resident (Resident A1) and accommodate individual food and beverage preferences, including the temperature served, to the extent practicable for four residents out of five sampled (Residents A1, A2, A3, and B2). Findings include: Random interviews conducted on October 18, 2023, with four alert and oriented residents, revealed that four residents expressed regarding the unpalatable temperature of food and beverages served and one resident expressed a concern regarding missing food, beverage, and condiment items from her meal tray. During an observation of the lunch meal on October 18, 2023, at 12:19 PM, Resident A1 stated she was not served coffee on her lunch tray as desired. Observation of the resident's meal tray, which was on her overbed tray table, revealed coffee was missing from her meal tray. The resident's meal tray ticket noted that the resident was to receive coffee with her…

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 scheduled mealtimes, select facility policy, the minutes from Menu Committee Meetings, and resident and staff interviews the facility failed to ensure the provision of a nourishing (satisfying to the resident) evening snack when greater than 14 hours elapsed from the supper meal to breakfast the next day for residents including four of five residents interviewed (Residents B2, A1, A2 and A3). Findings include: A review of facility's scheduled mealtimes revealed greater than 14 hours between dinner and breakfast (East Nursing Unit dinner at 4:30 PM and breakfast the next day at 7:45 AM for a total of 15 hours and 45 minutes; [NAME] Nursing Unit dinner at 5:00 PM and breakfast the next day at 8:15 AM for a total of 15 hours and 15 minutes; Pavilion Nursing Unit dinner at 5:30 PM and breakfast the next day at 8:50 AM for a total of 15 hours and 20 minutes. A review of facility policy titled HS (Bedtime) Snacks, dated July 2023, revealed that dietary and nursing staff will be responsible to provide evening supplementation to all residents. The 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.

Based on a review of clinical records, select facility policy and reports, and employee job descriptions and staff interview it was determined the facility's administration failed to effectively use its resources to promote resident safety by failing to assure that its staff implemented established procedures to maintain resident safety evidenced by one resident who eloped from the facility without staff awareness and his absence undetected for approximately three hours out of four sampled residents (Resident 146) Findings included: A review of an incident/accident report, facility investigation, and clinical record determined that on September 22, 2023, Resident 146 eloped from the facility and left the grounds without staff knowledge at around 1:30 PM. The conclusion of the facility's investigation, was that the resident had hitch hiked a ride to a nearby town, located approximately 16 miles away from the facility. Employee 3, LPN, who on September 22, 2023, had observed and spoken to Resident 146 outside the facility at approximately 1:30 PM, had failed to communicate his…

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 consistently implement measures planned to promote healing of an identified pressure ulcer for one of three residents sampled (Resident CR2). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. A review of the clinical record revealed that Resident CR2 was admitted to the facility on [DATE], with diagnoses to include diabetes and hypertension. A review of an Initial Pressure Skin Alteration Form dated August 14, 2023, at 2:54 p.m. revealed that the resident had a Stage II pressure area to his coccyx that measured 7 centimeter (cm) by 7 cm x 0.1 cm. A Wound Assessment Report dated August 16, 2023,…

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 clinical records and staff interviews it was determined that the facility failed to implement pharmacy procedures to assure timely acquiring and administration of medications to two of 13 sampled residents (Resident CR1 and CR3). Findings include: A review of Resident CR1's clinical record revealed that the resident was admitted to the facility on [DATE], status post hospitalization for a displaced fracture of the left fibula with diagnoses that included B-cell Lymphoma and Polyneuropathy. A review of Resident CR1's admission orders dated September 11, 2023, revealed an order for Pregabalin 200mg give one capsule every 12 for neuropathy start time at 9:00 PM. A review of Resident CR1's September 2023 medication administration record (MAR) revealed the resident did not receive his 9:00 PM dose on September 11, 2023, and his 9:00 AM dose on September 12, 2023. An interview with the Director of Nursing (DON) and Nursing Home Administrator(NHA) on September 21, 2023, at 2:23 PM revealed 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 clinical records, and staff interview, it was determined that the facility notify the physician as ordered for the potential need to alter treatment related to blood sugar level for one resident out of 13 sampled (Resident CR2). Findings include: A review of the clinical record revealed that Resident CR2 was admitted to the facility on [DATE], with diagnoses to include diabetes and hypertension. Resident CR2 had a physician order dated August 22, 2023, for blood glucose monitoring four times daily (6 AM, 11 AM, 4 PM, and 9 PM) with no insulin coverage orders at that time. However, the staff were to inform medical staff if the resident's blood sugar was over 250 milligrams per deciliter (mg/dL) or under 80 mg/dL. Review of the resident's Medication Administration Record (MAR) for August 2023, and September 2023, revealed Accu-checks results on August 23, 2023, at 11:00 a.m. of 258 mg/dL and 4:00 p.m. 308 mg/dL, August 24, 2023 at 9:00 p.m. 256 mg/dL, August 25, 2023 at 11:00 a.m. 261 mg/dL,…

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 nurse staffing, observations, and staff and resident interviews it was determined that the facility failed to provide and/or efficiently deploy sufficient nursing staff to consistently provide timely and quality of care to residents, including timely provision of nursing staff assistance to residents requiring the assistance of two nursing staff members for activities of daily living including two out of 32 sampled residents (Residents 65 and 116). Findings include: A review of the clinical record revealed that Resident 65 was admitted to the facility on [DATE], with diagnoses that included end stage renal disease (kidneys are no longer able to work at a level needed for day-to-day life) and diabetes mellitus. An admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated May 26, 2023, indicated that the resident was cognitively intact with a BIMS [Brief Interview of Mental Status-a tool 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 observation, resident and staff interviews and a review of select facility policy, it was determined the facility failed to consistently provide a fully functioning call system to provide direct communication from the resident to the caregivers for one of 32 residents sampled (Resident 94) and failed to ensure call bells were within reach for four of 32 residents sampled (Residents 94, 116, 141 and 7). Findings include: A review of facility policy titled Answering Call Bell last reviewed March 29, 2023, indicated that it is every employee's responsibility to answer call bells as noted on the scrolling [NAME] that is on each unit. Each nurse aide, Charge Nurse, and RN Supervisor is responsible to carry a pager on them to be notified of call bells. If the call bell or pager is defective and non-functioning, report this immediately to Maintenance for repair, and provide the resident with a hand bell until repair is complete. RN Supervisors are notified after 10 minutes if a call bell has been on for 10…

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.