Dubois Nursing Home

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to change an indwelling urinary catheter as ordered by the physician for one of 44 residents reviewed (Resident 137).Findings include:The facility policy for urinary catheter care, dated February 27, 2026, indicated that changing indwelling catheters or drainage bags at routine, fixed intervals, was not recommended. Rather it was suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system was compromised.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 137, dated February 17, 2026, revealed that the resident was cognitively intact, was dependent on staff for her daily care needs, had an indwelling urinary catheter, and had diagnoses that included neurogenic bladder (a lack of bladder control due to a brain, spinal cord, or nerve condition) and a urinary tract infection. Physician's orders for Resident 137, dated…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the physician of laboratory test results for one of 44 residents reviewed (Resident 123).Findings include: The facility policy for laboratory tests, dated February 27, 2016, indicated that the physician would be notified immediately if a test was obtained to monitor the blood level of a medication and the level was reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 123, dated February 24, 2026, revealed the resident was cognitively impaired, received anticoagulant medication (used to thin blood), and had a diagnosis of heart failure. The resident's care plan, dated March 3, 2026, indicated that he was at risk for bleeding due to anticoagulant therapy, and ordered labs were to be scheduled, results…

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

Based on review of facility policy and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care for one of seven residents reviewed (Resident 5). Findings include: Review of facility policy for oxygen administration by nasal cannula or mask dated February 27, 2026, indicated that residents who require oxygen will have a physician's order which includes the oxygen flow rate. An annual Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 5 dated January 22, 2026, indicated that the resident had moderate cognitive impairment, required assistance from staff for daily care needs, had diagnoses that included heart failure, and was receiving supplemental oxygen. Physician's orders for Resident 5 dated February 13, 2024, indicated that the resident was to receive oxygen at three Liters per minute (L/min) via nasal cannula (a lightweight, flexible tube with two small prongs that sits in the nostrils to deliver supplemental oxygen).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of seven residents reviewed (Resident 7).Findings include:CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were provided with proper colostomy care for one of four residents reviewed (Resident 4).Findings include: The facility's policy regarding colostomy care (care for an artificial opening in the bowel), dated January 31, 2025, colostomy care will be provided per physician orders to provide the stoma with good skin care and check the condition of the stoma and surrounding skin. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4 dated November 30, 2025,indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, had a diagnosis of sepsis (infection in the bloodstream) and had an ostomy (a surgically created opening in the abdomen- part of the body between the chest and the hips). A nurse's note for Resident 4, dated November 24, 2025, at 6:47 p.m.…

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

Based on review of facility policy and clinical records, as well as observations staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripherally inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) for one of four residents reviewed (Resident 4). Findings include: A facility policy for the care and maintenance of PICC and midline catheters (a small flexible tube inserted through a vein in your arm that is shorter than a PICC) dated January 31, 2025, indicated that dressing must stay clean, dry and intact. Dressings are to be changed every 5-7 days and as needed when wet, soiled, or not intact. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4 dated November 30, 2025,indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, had a diagnosis of sepsis (infection in the bloodstream) and had an ostomy (a surgically…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews and staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of four residents reviewed (Resident 1).Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 27, 2025, indicated that the resident was cognitively intact, required assistance with daily care needs, and had medical diagnoses that included malignant neoplasm of rectum. Physician's orders for Resident 1 dated December 11, 2025, included orders for the Registered Nurse to disconnect chemotherapy (medications used to treat cancer) pump, flush Medi port (an implanted device under the skin used to provide long term access to a vein for medications), and de-access the port every other Friday. Review of Resident 1's clinical record revealed no documented evidence that a Registered Nurse disconnected his chemotherapy pump, flushed the Medi port and de-accessed the port on December 12, 2025, or on…

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

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms for 10 of 14 residents reviewed (Residents 3 and 7).Findings include:The facility's policy regarding homelike environment, dated January 31, 2025, indicated that the purpose was to provide residents were provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.Observations of Resident 3 and 7's shared bathroom on November 20, 2025, at 11:13 a.m., 4:15, and 4:45 p.m. revealed that there was a brown/yellow removable substance on the toilet seat, on the metal safety rail, and there was brown removable substance around the inside of the bowl of the toilet.Interview with the Director of Housekeeping Services on November 20, 2025, at 4:45 p.m. revealed that the rooms were cleaned daily and COVID positive rooms to be last. She confirmed that the above residents' shared bathroom needed cleaning and indicated that staff…

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

Based on review of facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for dressing changes were followed for one of three residents reviewed (Resident 2).Findings include:A facility policy regarding physician orders, dated January 1, 2025, revealed that the licensed nurse would complete the physician order how it was written regarding timing and frequency.A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 4, 2025, indicated that the resident was severely cognitively impaired, could sometimes understand, was sometimes understood, required assistance from staff for all care needs, and had diagnoses that included dementia.A nursing note dated August 19, 2025, indicated that staff found a large skin tear. Resident 2 was assessed by a registered nurse and identified a seven centimeter (cm) by nine cm skin tear with bruising noted on the right forearm.Physician's orders for Resident 2, 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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's environment remained free of accident hazards by failing to ensure care-planned interventions were in place for one of 49 residents reviewed (Resident 17) who were at risk for falls, and failed to ensure that other residents' environment remained free of accident hazards from a resident with aggressive behaviors for one of 49 residents reviewed (Resident 93). Findings include: The facility's policy regarding fall prevention and management, dated January 31, 2025, indicated that the facility will identify those residents at risk for falls upon admission, readmission, and quarterly and provide appropriate interventions to modify and/or compensate for risk factors. The [NAME], point of care and point of care tasks will reflect all safety devices utilized as ordered. The care plan will be updated to reflect resident-specific safety needs and interventions. A…

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

Based on review of facility policies and clinical record, as well as and staff interviews, it was determined that the facility failed to provide appropriate treatment and services for two of 49 residents reviewed (Residents 38, 93) who had dementia. Findings include: The facility's policy regarding dementia care, dated January 31, 2025, indicated that residents living with dementia may experience agitation, aggression, distress or psychosis. Consideration should be given to non-pharmacological interventions prior to instituting a pharmacological treatment. It is the intent to use the lowest effective dose and utilize for the shortest time possible. A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated February 21, 2025, revealed that the resident was severely cognitively impaired, exhibited verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) which occurred one to three days, and had a diagnosis which included Alzheimer's…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 49 residents reviewed (Resident 62). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated March 11, 2025, revealed that the resident was cognitively intact, required assistance for care needs, and was taking an opioid medication (medications with the potential to be abused used to treat pain). Physician's orders for Resident 62, dated January 27, 2025, included an order for the resident to receive 50 milligrams (mg) of Tramadol (a narcotic pain medication) every six hours as needed for moderate to severe pain. Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 62, dated February, March and April, 2025, revealed that a 50 mg tablet of Tramadol was signed out on February 22 at 7:00 p.m.; March 1 at 7:22 p.m.;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, as well as resident and staff interviews, it was determined that the facility failed to develop an individualized care plan for three of 49 residents reviewed (Residents 26, 48, 110). Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 26, dated March 24, 2025, indicated that the resident was alert and oriented, had diagnoses that included diabetes, and was on a mechanically altered, therapeutic diet. Resident 26's care plan, dated March 24, 2025, revealed that it did not include any information or interventions related to the resident's nutritional needs. An interview with Resident 26 on May 12, 2025, at 9:31 a.m. revealed that she was not happy with the food choices she received and that she was not offered a snack at night, even though she was a diabetic. An interview with the Dietician on May 15, 2025, at 8:30 a.m. confirmed that Resident 26's care plan did not include anything regarding the resident's nutritional status and that it should have. 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 clinical record review, as well as staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for two of 49 residents reviewed (Residents 62, 126). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated March 11, 2025, revealed that the resident was cognitively intact, required assistance for care needs, was taking an antipsychotic medication (medications used to treat mental health disorders), and had diagnoses that included dementia. A nursing note for 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 review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that medications were provided as ordered by the physician for one of 49 residents reviewed (Resident 62). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated March 11, 2025, revealed that the resident was cognitively intact, required assistance for care needs, and had diagnoses that included hypertension. Physician's orders for Resident 62, dated April 30, 2024, included an order for the resident to receive 12.5 milligrams (mg) of metoprolol tartrate (treats hypertension) twice daily for hypertension. The medication was to be held if the resident's systolic blood pressure (the top number of a blood pressure reading) was 110 millimeters of mercury (mmHg) or less, or if the heart rate was less than 60 beats per minute. Physician's orders for Resident 62, dated April 8, 2025, included an order for the resident to receive 6.25 mg of metoprolol tartrate twice daily 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 review of facility policies, clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling urinary catheters for three of 49 residents reviewed who had an indwelling urinary catheter (Residents 55, 59, 106). Findings include: The facility's policy regarding indwelling urinary catheter (a flexible catheter used to drain urine from the bladder into a drainage collection bag) management, dated January 31, 2025, indicated to properly position the drainage bag below the level of the bladder to facilitate urine flow and avoid allowing the drainage bag or tubing to touch the floor. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 55, dated April 17, 2025, revealed that the resident was understood, could usually understand others, and had an indwelling urinary catheter. A care plan for the resident, dated January 10, 2025, revealed that the resident had an indwelling urinary catheter, and staff 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.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to flush a peripherally-inserted central catheter (PICC, a long, thin tube that is inserted through a vein in the arm and passed through to the larger veins near the heart), and a midline (a thin soft tube that's inserted through a vein in the arm and passed through to where the tip is at or near armpit level) as ordered by the physician for one of 49 residents reviewed (Resident 96). Findings include: The facility's policy regarding flushing central venous and midline catheters, dated January 31, 2025, indicated to flush catheters at regular intervals to maintain patency. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 96, dated March 31, 2025, indicated that the resident was cognitively intact, required assistance with care needs, received intravenous medications (medications delivered through a tube placed in a vein) while a resident, and had a diagnosis of anemia. Physician's orders…

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

Based on review of nurse aides' dates of hire and their most recent performance review dates, it was determined that the facility failed to complete annual nurse aide performance evaluations for two of three nurse aides reviewed (Nurse Aides 6, 7). Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation was due in November 2024 for Nurse Aide 6 and in January 2025 for Nurse Aide 7. However, there was no documented evidence that annual performance evaluations were completed as required for Nurse Aides 6 and 7. Interview with the Nursing Home Administrator on May 14, 2025, at 12:51 confirmed that she could provide no evidence that annual performance evaluations were completed as required for Nurse Aides 6 and 7. 28 Pa. Code 201.18(e)(1) Management.

Based on a review of facility policies and information provided by the facility, as well as observations and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures. Findings include: The facility's policy regarding temperatures for safe food handling, dated January 31, 2024, revealed that the temperatures of all food items will be taken and properly recorded prior to service of each meal. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit (F). All cold food items must be stored and served at a temperature of 41 degrees F or below. An interview with Resident 51 on May 12, 2025, at 1:10 p.m. indicated that his meals are often cold when his tray arrives. His room was toward the end of the hall and he indicated that it is often one of the last trays delivered. Observations of the lunch meal service in the main kitchen on May 13, 2024, revealed that the second north unit cart containing a test tray left the main kitchen at 12:30 p.m. and arrived on…

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

Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending June 27, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending May 15, 2025, identified repeated deficiencies related to failure to develop and implement comprehensive care plans, failure to provide quality of care, failure to provide a safe environment that is free of accident hazards, failure to provide appropriate treatment and services for residents with dementia, and failure to maintain compliance with the regulation regarding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain their infection prevention and control program for hand hygiene during wound care for one of 49 residents reviewed (Resident 59). Findings include: The facility's policy regarding hand hygiene, dated January 31, 2025, indicated that hand hygiene is an important infection control measure to prevent illness in skilled nursing homes, and that hands should be sanitized or washed before and after the use of gloves. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 59, dated March 31, 2025, indicated that the resident was understood and able to understand others. Physician's orders for Resident 59, dated May 7, 2025, included an order to cleanse the right heel surgical wound thoroughly with Vashe (a wound cleanser) and gauze. Apply silver calcium alginate (a type of silver infused wound dressing) on the wound bed, then cover with an ABD and wrap with kerlix and tape;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and cleaning schedules/documents, as well as observations and staff interviews, it was determined that the facility failed to ensure that essential kitchen equipment was maintained in a safe operating condition. Findings include: The facility's policy regarding routine stovetop cleaning, dated January 31, 2025, indicated that in order to keep all equipment at optimal levels of functioning and cleanliness, a routine cleaning schedule would be followed. Observations of the kitchen stove top on May 12, 2025, at 9:46 a.m. and May 13, 2025, at 8:38 a.m. and 1:37 p.m., revealed that there was a thick accumulation of black grease on and around four out of six stove top burners. These burners were located next to the grill area on the stovetop. Review of the kitchen cleaning schedule for April and May 2025 indicated that the stovetop was to be cleaned monthly. Interview with the Dietary Manager on May 14, 2025, at 11:08 a.m. confirmed that there was a large accumulation of heavy grease on and around four of the stovetop burners. She indicated that on April 1,…

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

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's responsible party was notified about a resident requiring oxygen for one of five residents reviewed (Resident 2). Findings include: The facility's policy regarding notification, dated January 25, 2024, revealed that staff will inform the resident's responsible party when there is a significant change in the resident's care or condition timely. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 8, 2024, revealed that the resident was cognitively impaired and required assistance from staff for daily care needs. A nursing note for Resident 2, dated August 11, 2024, revealed that the resident was having a hard time breathing and was coughing harshly. Staff applied oxygen for his comfort. A nursing note for Resident 2, dated August 12, 2024, revealed that the resident's family arrived and were concerned that he was wearing oxygen, and they had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs for three of 40 residents reviewed (Residents 50, 62, 101). Findings include: The facility's policy for care planning, dated January 25, 2024, indicated that all residents will have an interim, comprehensive, and ongoing plan of care, which will be developed and reviewed by the interdisciplinary team and resident. The plan of care is a working tool and requires changes as needed to meet the residents needs. The resident is to be viewed as a whole to develop a blueprint for care. Unique characteristics and needs are to drive the process. It must be individualized, realistic, functional, and measurable at time frame for completion. All goals are to be related directly to the problem. It is to outline and provide directions to provide care for the resident to meet the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to review and revise residents' care plans for five of 40 residents reviewed (Residents 2, 10, 22, 48, 105). Findings include: The facility's policy for care planning, dated January 25, 2024, indicated that the plan of care is a working tool and requires changes as needed to meet the residents' needs. The plan of care will also be reviewed and updated as needed during the change of status meeting. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 28, 2024, revealed that the resident was understood, able to understand others, required assistance with care needs, had two Stage 4 pressure ulcers (pressure wound with full thickness tissue loss with exposed bone, tendon or muscle), had complaints of pain rated a 5 of 10 on a pain scale of 0-10, and took routine and as-needed pain medication. A…

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

Based on review of facility policies, clinical records, and facility investigation reports, as well as observations and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls, by failing to follow physician-ordered and care-planned interventions for one of 40 residents reviewed (Resident 50), resulting in a fall; failed to ensure resident safety during transportation in a wheelchair for two of 40 residents reviewed (Residents 60, 80); and failed to ensure that air mattresses were assessed for potential safety hazards for one of 40 residents reviewed (Resident 61). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 50, dated April 2, 2024, revealed that the resident was usually understood, could usually understand others, and had diagnoses that included dementia and Parkinson's disease. A care plan for the resident, dated April 2, 2024, revealed that the resident was a high risk for falls…

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

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to enhance each resident's dignity by failing to provide clean durable medical equipment for one of 40 residents reviewed (Resident 105). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 105, dated May 23, 2024, revealed that the resident was somewhat understood and could somewhat understand others, and was dependent on staff for care care needs, including feeding assistance. A care plan for Resident 105 regarding an alteration in neurological status related to a cervical 4/cervical 5 surgical repair with discectomy (surgical removal of abnormal disc in the spine) indicated that the resident had a hard cervical collar (neck brace). Physician's orders for Resident 105, dated May 17, 2024, included an order for the resident to have a hard cervical collar in place at all time until further instructions were obtained from neurosurgery. Observations on June 24,…

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

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to accommodate the residents' needs by failing to ensure the proper positioning needed for eating for one of 40 residents reviewed (Resident 10) who had nutritional and self-care concerns. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated June 7, 2024, revealed that the resident was usually understood, could usually understand others, had a diagnosis which included dementia, had a weight loss of 5 percent or more in the last month and/or a weight loss of 10 percent or more in last six months, was not on a prescribed weight-loss regimen, and received a therapeutic diet (e.g., low salt, diabetic, low cholesterol). A care plan for the resident, dated November 16, 2020, revealed that the resident had a potential for weight fluctuations related to variable PO (by mouth) intake. The resident was to be up in a Broda chair (an adaptive wheelchair) for breakfast then laid back…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record reviews, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for a maintenance nursing program were followed for one of 40 residents reviewed (Resident 22) and failed to complete wound treatments as ordered for one of 40 residents reviewed (Resident 48). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated May 17, 2024, revealed that the resident was sometimes understood and sometimes able to understand others and required assistance with care needs. A care plan for Resident 22, dated April 19, 2011, indicated that the resident was to receive a maintenance nursing program consisting of active range of motion (person can actively range a part of the body) to her right lower extremity and passive range of motion (person needs assistance from someone else to range a part of the body) to her left lower extremity twice daily with a.m. and p.m. care. Physician's orders for Resident 22, dated 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.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for one of 40 residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 28, 2024, revealed that the resident was understood, able to understand others, required assistance with care needs, and had two Stage 4 pressure ulcers (pressure wound with full thickness tissue loss with exposed bone, tendon or muscle). Physician's orders for Resident 2, dated January 25, 2024, included an order for the staff to clean the wound to the left ischium with Vashe wound cleanser (used to cleanse and debride wounds) and pat dry, pack wound with a piece of silver calcium alginate (dressing used to aid in wound healing), and cover with a foam dressing daily every day shift. A review of the resident's Treatment Administration Record (TAR) for April 2024 revealed that 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.

Based on review of facility policies and clinical records, as well as staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for one of 40 residents reviewed (Resident 50). Findings include: The facility's policy regarding Trauma Informed Care, dated January 25, 2024, revealed that upon admission the facility will assess each resident to ensure they receive appropriate treatment and services. A questionnaire will be utilized for each resident by the social services department to identify any trauma and/or post-traumatic stress disorder and to gather trigger information, so that our understanding of their traumatic events can be detailed and specific. Additional information may be obtained from the medical record, physical and emotional assessments, from the resident, from family members who have shared this information.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, and staff interviews, it was determined that the facility failed to provide appropriate treatment and services for one of 40 residents reviewed (Resident 30) who had dementia. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 30, dated [DATE], revealed that the resident was sometimes understood, could sometimes understand others, and had diagnosis that included dementia and Parkinson's disease. A care plan for the resident, dated [DATE], revealed that the resident has an impaired cognitive function or impaired thought processes related to Parkinson's disease. Staff were to provide the resident with a homelike environment: visible clocks, a calendar, low-glare light, consistent care routines, familiar objects, and reduced sensory noise. Physician's orders for Resident 30, dated [DATE], and discontinued on [DATE], included an order for the resident to receive one 25 milligram (mg) tablet of…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for the State Survey and Certification (Department of Health) surveys ending July 27, 2023, and April 10, 2024, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending June 27, 2024, identified repeated deficiencies related to a failure to accommodate a resident's needs, to develop comprehensive care plans, to update residents' care plans, and to ensure that the residents' environment remained free from accident hazards. The facility's plan of correction for a…

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

Based on review of established infection control guidelines and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 40 residents reviewed (Residents 17). Findings include: CDC guidance on isolation precautions for MRSA residents contained in Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicates that multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS…

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