Transitions Healthcare Allens Cove

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for one of three residents reviewed for hospitalization (Resident 45). Findings Include: Review of facility policy, titled Bed Holds and Returns and Therapeutic Leave of Absence, last dated January 3, 2024, revealed The Facility is required to provide a bed hold under certain circumstances and make the Resident aware of the Facility's bed hold and return policy as related to hospitalization and therapeutic leave. The facility will provide information on bed hold requirements to all residents upon admission and again at time of transfer from the Facility. Bed Hold requirements will be included in the Facility admission packet to be reviewed during the admission process and will be considered the first notice of the Facility Bed Holds and Returns policy .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 clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 19 residents reviewed (Residents 9 and 32). Findings Include: Review of Resident 9's clinical record revealed diagnoses that included Multiple Sclerosis (MS - a disease that causes breakdown of the protective covering of nerves; can cause numbness, weakness, trouble walking, vision changes, and other symptoms) and neurogenic bladder (bladder dysfunction caused by nervous system conditions). Review of Resident 9's physician orders revealed an order dated June 28, 2024, for a Foley catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine; also known as an indwelling catheter). Review of Resident 9's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) dated February 16, 2025,…

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

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good grooming and personal hygiene for one of two residents reviewed for ADLs (Resident 23). Findings Include: Review of the facility policy, titled Activities of Daily Living last reviewed May 31, 2024, read, in part, Residents will gain and/or maintain as much independence as possible in ADLs which are essential to the individual's lifestyle. This refers to activities an individual performs on a regular basis, such as eating, dressing, hygiene (make-up, shaving, washing), transfers, reading, writing, housework, smoking, walking, and even driving. The resident's performance may vary depending on the time of day, how the resident feels, setting, and the person with him/her. Review of Resident 23's clinical record revealed diagnoses that included spinal stenosis (a condition that narrows the space in the spine, putting pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of one of 16 residents reviewed (Resident 24). Findings include: Review of Resident 24's clinical record revealed diagnoses that included Alzheimer's disease (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), atrioventricular heart block (a type of heart block that occurs when the electrical signal traveling from the atria, or the upper chambers of the heart, to ventricles, or the lower chambers of the heart, is impaired), and presence of a cardiac pacemaker. Observation of Resident 24 on April 21, 2025, at 10:02 AM, revealed the presence of a [NAME] at Home (a remote telephonic pacemaker check device) on her bedside stand. Review of…

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

Based on review of clinical records and staff interviews, it was determined that the facility failed to provide restorative nursing care for range of motion exercises for one of three residents reviewed for position and mobility (Resident 29). Findings include: Review of Resident 29's clinical record revealed diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder) and hypertension (high blood pressure). Review of Resident 29's clinical record revealed a Restorative Program Progress Note written on February 24, 2025, at 12: 17 PM, that read, in part, restorative nursing programs from passive range of motion (PROM) of right upper extremity (RUE) and right lower extremity (RLE) and active range of motion (AROM) of left lower extremity (LLE) continue. Resident 29 has a diagnosis of flaccid hemiplegia to right side; she is able to tolerate both PROM programs to right upper and lower extremities and continues to participate and complete three sets of ten reps for each of the exercises listed within the AROM LLE programs. Review of Resident 29's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to the preparation and administration of medications for three of three residents observed (Residents 9, 27, and 155). Findings include: Review of facility policy, titled General Guidelines for Medication Administration with a last revised date of August 2020, and a last review date of May 2024, revealed the following, The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: i. Before beginning a medication pass; ii. Prior to handling any medication; iii. After coming into direct contact with a resident and Hand sanitization is done with a facility approved sanitizer ii. At regular intervals during the medication pass such as after each room, again assuming handwashing is not indicated. Review of facility policy, titled Transitions Healthcare Allen's Cove IC-Infection Control Plan 2024…

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

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like environment in common areas and one of three resident rooms observed (South and East Hallways, Nurses Station, and Resident 1's room). Findings include: Review of facility policy, titled Cleaning & Disinfecting Environmental Surfaces last revised October 1, 2017, read, in part, Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. Observation in the South Hallway on March 31, 2025, at 10:41 AM, revealed three ceiling tiles with ring circle stains on them. Observation at the Nurse's Station on March 31, 2025, at 10:44 AM, revealed a large ceiling tile to the left of the station with a large brown ring circle stain. Observation in the East Hallway on March 31, 2025, at 10:46 AM, revealed one ceiling tile with a large brown ring circle stain on it, and a brown liquid stain that was dripping down the side of the wall. Further…

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

Based on employee handbook review, review of select facility documentation, and staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least once every 12 months for three of five nurse aides reviewed (Employees 2, 3, and 4). Findings include: Based on facility document, titled Employee Handbook effective July 1, 2022, read, in part, All employees will be subject to a written annual rating and evaluation by the department supervisor based on his/her employment anniversary date to ensure that strengths, areas for improvement, and job goals for the next review period have been clearly communicated. An employee's evaluation will be reviewed with the employee by the supervisor at the time of presentation for the employee's signature. Review of select facility documentation revealed a list of nurse aide's that had worked at the facility for greater than a year. Employee 2 had a hire date of January 5, 2024; Employee 3 had a hire date of April 15, 2023; and Employee 4 had a hire date of July 1, 2022. During an…

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

Based on observations, facility policy review, and staff interviews, it was determined that the facility failed to prepare and store food and equipment in accordance with professional standards for food service safety in the main kitchen area. Findings Include: Review of facility policy, titled Food Storage, dated 2021, revealed All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Review of facility policy, titled General Food Preparation and Handling, dated 2021, revealed The kitchen will be kept neat and orderly. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. Upon entering the kitchen on September 4, 2024, at 9:29 AM, with the Nursing Home Administrator (NHA) and Employee 1 (Food Service Director), Employees 2 (Cook) and 3 (Dietary Aide) were observed working in the kitchen without hairnets. Employee 1 immediately provided hairnets to Employees 2 and 3. Observation of the dry storage area in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to provide notice of transfer to the Office of the State Long-Term Care Ombudsman, after a transfer out of the facility, for four of four residents reviewed for hospitalization (Residents 10, 14, 26 and 57). Findings include: Review of Resident 10's clinical record revealed diagnoses that included chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should be) and hypertension (high blood pressure). Further review of Resident 10's clinical record revealed that she was transferred and admitted to the hospital on [DATE]. During an interview with the Nursing Home Administrator (NHA) on May 9, 2024, at 10:10 AM, he stated that the Office of the State Long-Term Care Ombudsman was not notified of Resident 10's transfer to the hospital. Review of Resident 14's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure one of two residents reviewed for activities of daily living was provided care and services in regard to hygiene and bathing (Resident 32). Finding include: Review of Resident 32's clinical record revealed diagnosis that included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and hypoxemia (low levels of oxygen in the blood). During an interview with Resident 32 on May 6, 2024, at 10:35 AM, she revealed that she didn't get washed up the previous morning (May 5, 2024). Review of Resident 32's clinical record tasks revealed a restorative nursing program for activities of daily living (ADLs) for 15 minutes twice daily, that includes the resident washing and drying her face, hands, and upper body with mid-mod assist from staff and perform her grooming with set-up assist. Review of Resident 32's clinical record revealed a Restorative Program Note written on March 8, 2024, at…

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

Based on resident interviews, staff interviews, and facility document review, it was determined that the facility failed to provide an ongoing activities program designed to meet the physical, mental and psychosocial well-being for five out of five residents who attended group for Resident Council (Resident 2, 13, 39, 51, and 260). Findings include: An interview with Employee 3 on May 7, 2024, at 11:30 AM, revealed that the facility only has one activity staff member who works Monday through Friday, and that they do not hold activities for residents on weekends. Interviews with resident's during a group interview on May 8, 2024, at 9:00 AM, revealed the facility does not have any activities held on weekends for the residents, that scheduled activities sometimes get cancelled, and that the resident's feel the activity director needs help. Review of the facility's Resident Council Meeting Minutes from March 2024 revealed the following comments regarding activities: Activities have gone downhill. The activities director has not been here, residents are left alone in dayroom. Aides are…

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

Based on review of the dietary extension sheets (guidelines as to what foods should or should not be served for specific therapeutic diets), the Diet Type facility report and staff interview it was determined that the facility failed to provide a therapeutic diet per physician's order, for four residents on a Renal/ low potassium diet (a diet aimed at keeping levels of fluids, electrolytes, and minerals balance in the body in individuals who's kidneys don't function as they should or who receive treatments to remove excess water, solutes and toxins from the blood due to kidney failure) and 18 residents on a Consistent Carbohydrate diet (CCD- meals are planned to provide a consistent amount of carbohydrates day to day.) out of 22 residents reviewed on a therapeutic diets. Findings include: On May 8, 2024, review of facility report Diet Type, printed May 8, 2024; documented the following therapeutic diet were prescribed: eighteen residents were ordered consistent carbohydrate diet, and four residents were ordered a renal/low potassium. The in house census on May 8, 2024, was 55…

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

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for four of four residents reviewed for respiratory care (Residents 14, 31, 32 and 111). Findings Include: Review of facility policy titled Aerosol Therapy, with a revision date of Mach 21, 2016, revealed, in part, to wash and air dry the nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) after use. When nebulizer equipment is dry, place it back in labeled plastic bag. Plastic bag will have the date that the equipment was opened on the outside of the bag Change aerosol unit, mouth piece, tubing and plastic bag on a weekly basis and label with date. Review of facility policy titled Oxygen Concentrators, with a revision date of January 26, 2017, revealed DO NOT keep distilled water in a resident's room. Always date an opened bottle. Review of Resident 14's clinical record revealed diagnoses that included chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility policy, and interview it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen area and one of one nourishment pantry. Findings include: Review of facility policy Food Storage, dated 2021, read, in part, all stock must be rotated with each new order received, old stock will be utilized first. Food should be dated as it is placed on the shelves. All storage containers or storage [NAME] must be accurately labeled and dated. Leftover food must be used within seven days or discarded as per the 2017 Federal Food Code. Observation in the dry store room on May 6, 2024, at 9:25 AM one half package of pasta was open and not securely closed. During an interview with Employee 5, Food Service Director, on May 6, 2024, at 9:25 AM it was revealed that the past should've been securely closed. Observation in the walk-in refrigerator on May 6, 2024, at 9:30 AM one container of thirty hard boiled…

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

Based on observations, facility policy review and staff interview, it was determined that the facility failed to ensure each resident the right to a dignified existence during meal service for one of one dining rooms observed. Findings Include: Review of facility policy titled Resident Rights, with a revision date of May 5, 2023, revealed Provide meals to all Residents at each table at the same time. Observation in the dining room during lunch on May 6, 2024, at 12:59 PM, revealed Residents 6, 10, 17, 30 and 50 all sitting at a table. Resident 50 was observed to be eating her lunch, while Residents 6, 10, 17 and 30 had not yet been served their lunch. Additional observations revealed the following: At 1:04 PM, Resident 30 was served her lunch. At 1:08 PM, Resident 6 was served her lunch. At 1:12 PM, Resident 17 was served her lunch. At 1:25 PM, Resident 10 was served her lunch. Further observations in the dining room during lunch on May 6, 2024, revealed there were 19 residents total eating in the dining room. Observations revealed all 19 residents were eating their lunch served 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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide residents with a copy of the facility's bed-hold policy as a result of a transfer out of the facility for three of four residents reviewed for hospitalization (Residents 10, 14 and 26). Findings Include: Review of facility policy titled Bed Holds and Returns and Therapeutic Leave of Absence, revised September 28, 2022, revealed The Facility will provide information on bed hold requirements to all residents upon admission and again at time of transfer from the Facility. Bed Hold requirements will be included in the Facility admission packet to be reviewed during the admission process and will be considered the first notice of the Facility Bed Holds and Returns policy .The second notice, which details the duration of the bed hold policy, will be issued at the time of transfer. In cases of emergency transfer, notice 'at the time of transfer' means that the family, surrogate, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 17 residents reviewed (Resident 21 and 32). Finding include: Review of Resident 21's clinical record contained diagnosis that included: dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), Parkinson's disease (disorder of the central nervous system that affects movement), moderate protein calorie malnutrition (moderately-malnourished, protein and energy intake doesn't meet nutritional needs), and psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality). Further review of Resident 21's clinical record on May 6, 2024, at 12:46 PM documented that Resident 21 had been on Hospice services since November 15, 2023. Review of Resident 21's quarterly Minimum Data Set (MDS- part 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 clinical record review and staff interview, it was determined that the facility failed to ensure that a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for one of 17 residents reviewed (Residents 261) Findings include: During an interview with Resident 261 on May 7, 2024, at 9:00 AM it was revealed that she resided in Personal Care prior to hospitalization and then admission into skilled nursing care on May 3, 2024. It was also revealed she had been on hemodialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer preform these functions naturally) for some time, and received hemodialysis on Monday, Wednesday, and Friday outside of the nursing facility. Review of resident 261's clinical record documented diagnoses that included protein calorie malnutrition (moderately-malnourished, protein and energy intake doesn't meet nutritional needs), dependence on hemodialysis, and diabetes mellitus (the…

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

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide routine drugs to its residents and ensure procedures to assure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for one of 17 residents reviewed (Resident 111). Findings Include: Review of Resident 111's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe) and obstructive sleep apnea (intermittent airflow blockage during sleep). During an interview with Resident 111 on May 6, 2024, at 10:20 AM, she stated that she wants her nicotine patch but is still waiting for it. She said she was told that the facility has not yet received it. Review of Resident 111's clinical record revealed an order for a Nicotine patch, with a start date of May 1, 2024, apply one patch once a day for smoking cessation. Review of Resident 111's medication administration record (MAR), dated May 2024, revealed…

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

Based on observation, review of facility policy, and resident and staff interviews, it was determined that the facility failed to provide food and beverage that are at a safe and appetizing temperature for one of one meal observed on the South unit. Findings include: Review of facility policy Hazard Analysis Critical Control Points and Food Safety, dated 2021, read, in part, staff will recognize potentially hazardous foods such as milk, and milk products, poultry, shell eggs, and meat and handle them carefully. The Director of Food Service and Registered Dietitian should determine the appropriate temperature ranges for the food service operation. The United States Department of Health and Human Services Food Code uses 41 degrees Fahrenheit for cold foods and 135 degrees for hot foods. Review of resident council meeting minutes for February 8, 2024, and March27, 2024, documented resident concern with cold food. Resident interviews during the initial pool process revealed concerns with the temperature of the food and beverages during meal service. Test tray completed on May 6, 2024,…

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

Based on observations and staff interview, it was determined that the facility failed to maintain a safe, clean, and home-like environment in one of one dining room. Findings Include: Observation of the dining room on November 13, 2023, at 10:45 AM, 11:36 AM, 12:30 PM, and 1:35 PM, revealed eight sets of windows with windowsills. Observations of all of the windowsills in the dining room revealed numerous tiny dead black bugs. Further observations revealed additional tiny dead black bugs located on the registers below the windowsills, as well as on the floor below the windows. On November 13, 2023, at 1:45 PM, the Nursing Home Administrator (NHA) was shown the dead bugs in the dining room. At that time, he stated that the bugs appeared within the last week when the weather went from cold to warm. The NHA immediately notified housekeeping to clean the area. 28 Pa. Code 201.18(e)(2.1) Management

Based on observation, review of facility policy, service line temperature log, and resident and staff interviews, it was determined that the facility failed to provide food and beverage that are palatable and at a safe and appetizing temperature for five of 13 meals reviewed. Findings include: Review of facility policy, titled Food: Quality and Palatability with a last revised date of September 2017, revealed Food will be palatable, attractive, and served at a safe and appetizing temperature. Review of the facility's Service Line Checklist revealed that Hot Food Temperatures should be equal to or greater than 135 degrees Fahrenheit, and Cold food temperatures should be less than or equal to 41 degrees Fahrenheit. Review of these checklists from July 28, 2023, through August 9, 2023, revealed the following concerns: July 28, 2023, dinner meal: the grilled cheese temperature was documented as 130 degrees Fahrenheit, not palatable temperature; July 29, 2023, lunch meal: the french fries temperature was documented as 134 degrees Fahrenheit, not palatable temperature; July 30, 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 observations and resident and staff interviews, it was determined that the facility failed to note or update menu changes and notify Residents of a change to the posted menu for one of one meals observed (August 10, 2023, lunch meal). Findings include: During an interview with Resident 1 on August 10, 2023, at 11:05 AM, they indicated that they do not always get their preferences, and that they have not been getting dinner rolls as listed on the menu. During an interview with Resident 3 on August 10, 2023, at 12:10 PM, they indicated that they do not always get what is listed on the menu. Observation of Resident 3's lunch tray on August 10, 2023, at 12:15 PM, revealed that they had not received their roll or margarine as indicated on their tray ticket. Observation of Resident 4's lunch tray on August 10, 2023, at 12:25 PM, revealed that they had not received their dinner roll or unsweetened tea as indicated on their tray ticket. In addition, the tray ticket stated Send 2 butter cups with all meals. There were no butter cups noted on the tray. During an interview with…

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