Sapphire Care And Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, select facility policy review, and staff interview, it was determined the facility failed to ensure a resident was free from a chemical restraint and failed to ensure non-pharmacological interventions were attempted and documented prior to administration of a psychotropic medication for one of 10 residents reviewed (Resident CR1). Findings include: A review of the facility policy titled Use of Psychotropic Medication, last reviewed by the facility on February 24, 2026, revealed it is the facility policy to ensure residents do not receive psychotropic medication (medications that affect the chemical makeup of the brain and nervous system, altering mood, cognition, and perception) that are not clinically indicated and necessary to treat a specific condition documented in the medical record. The policy also indicated that behavioral and other non-pharmacological approaches (non-medication approaches used to manage symptoms or behaviors, such as environmental, behavioral, 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 a review of select facility policies, clinical record review, and staff and resident interviews, it was determined that the facility failed to promptly notify a resident's designated representative and power of attorney of a significant change in the resident's condition and new treatment orders, for one resident out of eight sampled (Resident 1). Findings include: A review of the facility's policy Change in a Resident's Condition or Status last reviewed by the facility July 2025, indicated the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and /or status. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. Except in emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition 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, select facility policy, and staff interviews, it was determined the facility failed to provide professional standards of practice for diabetes management for one resident out of 29 sampled (Resident 119). Findings include: A review of facility policy entitled Administering Medications, last reviewed on August 7, 2025, revealed that medications must be administered in accordance with the physician's orders and if the dosage is believed to be inappropriate or excessive for a resident or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss the concerns. A review of Resident 119's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (brain damage that results from 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 observations and staff interviews, it was determined that the facility failed to demonstrate an effective maintenance program of inspection of all bed frames with bed extenders to assure the limiting of entrapment zones and promote resident safety for two residents out of 29 sampled (Resident 1 and Resident 7) and in three resident rooms observed.Findings included: Entrapment is a situation in which a resident's head, neck, chest, or limbs can become trapped between parts of a hospital bed system such as the mattress, bed frame, side rails, or footboard. The U.S. Food and Drug Administration (FDA) and the Centers for Medicare & Medicaid Services (CMS) according to Guidance for Industry and FDA Staff: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued March 10, 20026 identify seven potential entrapment zones, including the space between the mattress and the footboard of the bed (Zone 6). Zone 7 Between the Head or Foot Board and the End of the Mattress When there is too large of a space between the inside surface of the headboard or footboard…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility policy, and staff interviews, it was determined that the facility failed to follow its own policies and procedures for monitoring nutritional status, obtaining weights, completing reweights, and ensuring timely notification of significant weight changes for six of ten sampled residents (Residents 16, 18, 21, 97, 107, and 119). Findings include: A review of the facility's Nutritional Assessment Policy last reviewed August 7, 2025, indicated that as part of the comprehensive assessment, a nutritional assessment, including nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by change in condition that place the resident at risk for impaired nutrition. The nutritional assessment will be conducted by the interdisciplinary team and identify components…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, it was determined that the facility failed to ensure the availability of a functioning bed for all current licensed and certified resident beds on two of three resident care units, (first floor and second floor).Findings include: The facility is licensed and certified by the State and the Centers for Medicare & Medicaid Services (CMS) for a specific number of resident beds. The facility must provide residents with bedrooms that are appropriately furnished with a bed, mattress, and related equipment in accordance with the facility's license and certification. Licensed capacity, in plain terms, is the maximum number of residents the facility is legally permitted and expected to be accommodated at any given time. Beds must be physically present to demonstrate that the facility is able to provide immediate, safe, and appropriate accommodations for its licensed capacity, and not merely maintain bed space on paper. Observations made during an environmental tour August 14,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, select facility policy, and resident and staff interviews, it was determined the facility failed to reasonably accommodate residents' need for call bell accommodation for one out of 29 residents sampled (Resident 18).Findings include: A review of a facility policy titled Call Light Policy, last reviewed by the facility on August 7, 2025, revealed that it is the policy to ensure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Further review revealed that each resident will be evaluated for unique needs and preferences to determine any special accommodation that may be needed for the resident to utilize the call system, and any special accommodations will be identified on the resident's person-centered plan of care and provided accordingly, with examples to include touch pads, larger buttons, and bright colors. A review of Resident 18's clinical record revealed that 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 clinical record review and staff interview, it was determined the facility failed to demonstrate that a resident's discharge from the facility was appropriate and necessary, for one of three sampled residents (Resident 112).Findings include: Clinical record review revealed that Resident 112 was admitted to the facility on [DATE], with diagnoses to include acute kidney failure (an abrupt decrease in kidney function, resulting in the retention of waste products) and unsteadiness on feet. Review of an entry Minimum Data Set Assessment (MDS a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated July 7, 2025, indicated the resident had a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 14 indicating she was cognitively intact. A review of Resident 112's hospital discharge history and physical paperwork from July 7, 2025, revealed the resident had been hospitalized in part due to her inability to care for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, the Resident Assessment Instrument, and staff interview, it was determined the facility failed to ensure that Minimum Data Set Assessments accurately reflected the status of two residents out of 29 sampled. (Residents 21 and 72).Findings include: According to the Resident Assessment Instrument (RAI) User's Manual (an assessment tool utilized to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan, and the RAI also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status) dated October 2024, Section K0300 Weight Loss the facility is to record loss of 5% or more in the last month or loss of 10% or more in the last 6 months. A clinical record review revealed Resident 21 was admitted to the facility on [DATE]. Resident 21 was transferred to the hospital on July 17, 2025, and readmitted to the facility on [DATE]. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, resident observation, and staff interview, it was determined the facility failed thoroughly assess and timely implement treatments to an identified skin impairment for one resident out of 29 sampled residents (Resident 16). 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. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, physician orders, resident interview, and staff interview, it was determined the facility failed to provide restorative nursing services and a therapeutic device prescribed to maintain mobility and current level of functioning as ordered by the physician and recommended by rehabilitative therapy staff for one resident (Resident 4) out of five sampled residents. Findings include: Review of the facility Restorative Nursing Services Policy last updated August 7, 2025, indicated that residents will receive restorative nursing care as needed to help promote optimal safety and independence. Residents may be started on a restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. The resident or resident representative will be included in determining goals and the plan of care. A review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 controlled drug shift count records, select facility policy, observations of the medication cart, and staff interviews, it was determined that the facility failed to implement procedures to promote accurate documentation of controlled medications for one of three medication carts reviewed (first floor, back cart). Findings include: A review of facility policy entitled Controlled Substances last reviewed on August 7, 2025, revealed that nursing staff must count controlled medications at the end of each shift. The policy further stated that the nurse coming on duty and the nurse going off duty must complete the count together and that both nurses are required to sign the record to verify accuracy. In addition, the policy directed that any discrepancies must be reported to the Director of Nursing Services immediately A review of controlled drug records (also known as narcotics are medications that are regulated by federal law due to their high risk of abuse or misuse) for the first-floor, back medication cart revealed multiple instances in which the required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of manufacturer instructions, and staff interviews, 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 three medication carts (first floor, back cart).Findings include: A review of the facility policy titled Storage of Medications, last reviewed by the facility on August 7, 2025, revealed that the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals and that all such drugs shall be returned to the dispensing pharmacy or destroyed. A review of manufacturer instructions for Humalog Kwik Pen, Basaglar Kwik Pen, and Humalog Insulin vials revealed that these medications must be stored in the refrigerator until ready for use. Once removed from refrigeration, the insulin vials and pens may be used for up to 28 days. After 28 days, they are to be discarded. On August 14, 2025, at approximately 9:00 A.M., an observation of the first floor, back medication cart was conducted in the presence of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policy and clinical records, and staff interview, it was determined the facility failed to timely notify the resident's interested representative of a change in condition for one resident out of 20 sampled (Resident 19). Findings include: A review of the facility's policy Change in a Resident's Condition or Status last reviewed by the facility January 2025, indicated the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and /or status. A review of the clinical record revealed Resident 19 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions), and hypertension (high blood pressure). The resident's clinical record identified an emergency contact as their designated representative. A quarterly Minimum Data Set assessment (MDS- standardized assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's infection control tracking log, observations, and staff interview, it was determined that the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility, including protocols and provisions for Enhanced Barrier Precautions for 6 of six residents observed (Residents 70, 66, 52, 12, 83, and 33). Findings include: A review of a memo from The Center for Clinical Standards and Quality/Quality, Safety & Oversight Group, Ref: QSO-24-08-NH, CDC, Centers for disease control, dated March 20, 2024 regarding, Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of disease revealed, CMS is issuing new guidance for State Survey Agencies and long term care (LTC) facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards. EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless 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 staff interview, it was determined the facility did not have one or more individuals serving as the Infection Preventionist (IP) responsible for the facility's infection prevention plan. Findings included: The Centers for Medicare and Medicaid Services regulation §483.80(b)(3) states the facility must designate one or more individuals as the infection preventionist (IP) who are responsible for the facility's Infection Prevention and Control Program. The IP must work at least part-time at the facility, physically work onsite in the facility, cannot be an off-site consultant, or perform the IP work at a separate location. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on October 22, 2024, at 11:40 AM, revealed the prior IP left the role in the beginning of April 2024, and there was currently no designated IP. Further they stated the facility has hired a new IP but she had not started in the position as of the end of survey October 25, 2024. In an interview on October 24, 2024, at 9:47 a.m., the Director of Nursing confirmed that…

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

Based on a review of the facility's abuse prohibition policy and employee personnel files and staff interviews, it was determined the facility failed to fully develop and implement established abuse prohibition procedures for screening five of five employees for employment. (Employee 3, 4, 5, 6, and 7) Findings include: According to regulatory requirements under §§483.12(a)(3) and 483.12(b)(1) the facility must have written procedures for screening prospective employees, to include reviewing: the employment history (e.g., dates of employment position or title), particularly where there is a pattern of inconsistency; information from former employers, whether favorable or unfavorable; and/or documentation of status and any disciplinary actions from licensing or registration boards and other registries. A review of the facility's Resident Abuse policy last reviewed by the facility January 24, 2024, revealed no procedures for screening potential employees that included obtaining references from current/previous employers. Review of employee personnel files revealed that Employee 3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview it was determined the facility failed to maintain an environment free of potential accident hazards during medication administration on one of two resident care units. (First floor). Findings include: An observation on the first floor nursing unit on October 24, 2024, at 8:56 AM, during medication administration revealed there were medications located on overbed table in room [ROOM NUMBER]-1. One clear plastic medication cup with what appeared to be crushed medications in a liquid, a second medication cup with a red colored liquid, and a large plastic cup filled with a pink liquid, on Resident 83's overbed table. During an interview with Resident 83, who resides in room [ROOM NUMBER] on October 24, 2024, at 8:56 AM revealed the resident stated the nurse left the medications on the table. Resident 83 further stated, she will give them to me eventually. A review of Resident 83's Medication Administration Record (MAR) dated October 2024, revealed the resident was scheduled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, a review of clinical records and staff interview, it was determined the facility failed to provide the necessary care and services to prevent potential urinary tract infections to the extent possible for one resident with an indwelling urinary catheter out of 20 sampled residents (Residents 83). Findings included: A review of Resident 83's clinical record revealed the resident was admitted on [DATE], with diagnoses, which included retention of urine and required the use of an indwelling catheter for urination. Review of physician orders revealed an order dated October 4, 2024, for Acetic Acid irrigation solution 0.25%, use 1 dose via irrigation every day and evening shift. The physician order failed to identify what was to be flushed or the amount of Acetic Acid to be administered. Observation of Resident 83's room on October 22, 2024, at 10:25 a.m. revealed there were two opened irrigation kits with a piston syringes and two opened undated bottle of Acetic Acid 0.25% behind each…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and staff interview, it was determined the facility failed to follow physician orders for oxygen therapy and failed to maintain oxygen equipment in a functional and sanitary manner for three residents out of 20 sampled (Residents 28, 61, and 52). Findings include: Review of the facility policy titled Equipment Changing last reviewed by the facility on January 24, 2024, revealed that all respiratory equipment must be changed in order to prevent nosocomial infections (healthcare associated infections). The equipment should be marked with the date that it was changed. All equipment should be changed on a weekly basis as well as prn (as needed) if it becomes soiled or falls on the ground. Review of Resident 28's clinical record revealed the resident was initially admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disease (COPD- lung disease that blocks airflow and makes it difficult to breathe), 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.

Based on a review of clinical records, select facility policy, and medication records, and staff interviews, it was determined that the facility failed to implement pharmacy procedures for accounting for controlled drugs on one of six medication carts. (First Floor Back) Findings included: A review of the facility's policy entitled Controlled Substances last reviewed by the facility on January 24, 2024, revealed that nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They much document and report any discrepancies to the Director of Nursing services. A review of the facility's Change of Shift Controlled Substances Count Sheet revealed that the signature of nurse arriving on duty and nurse departing from duty indicates that controlled drugs on the cart have been counted and that the quantity of each medication counted is in agreement with the quantity stated on the Daily Narcotic Count Sheet and that the controlled substance log was reconciled and found to be accurate.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that the attending physician acted upon on the pharmacist's reports of irregularities in the drug regimen of four resident of 20 residents reviewed (Residents 28, 10, 73, and 36). Findings include: A review of Resident 28's clinical record revealed admission to the facility on April 17, 2024, with diagnoses to include Thrombophilia (blood disorder that makes the blood in the veins and arteries more likely to clot), chronic obstructive pulmonary disease (COPD- lung disease that blocks airflow and makes it difficult to breathe), and chronic respiratory failure with hypoxia (not enough oxygen passes from the lungs to the blood, making it difficult to breath). A review of the consultant pharmacist's Consultant Pharmacist Communication to Physician dated August 13, 2024, addressed the physician's order for Lovenox (an anticoagulant- blood thinner used to prevent blood clots). The pharmacist recommended 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 clinical records and staff interviews, it was determined that the facility failed to ensure that a resident was free from unnecessary psychoactive drugs by failing to ensure the presence of clinical rationale for the continued use of an as needed psychotropic medication for two of five residents reviewed (Residents 44 and 20). Findings include: A review of Resident 44's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include Bipolar Disorder (a mental illness that causes extreme mood swings, along with changes in energy, sleep, thinking, and behavior). A review of Resident 44's clinical record revealed a physician's order for lorazepam (used to treat anxiety) give 0.5 mg by mouth every 12 hours as needed for Anxiety with a start date of September 9, 2023, and no end date . A review of the October 2024 Medication Administration Records (MAR) revealed that the medication (alprazolam) was administered to the resident four times during the month of…

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

Based on a review of select facility policy, observations, and staff interview, it was determined that the facility failed to adhere to acceptable storage and use by dates for multi-dose medication on two of six medication carts observed. Findings include: A review of facility policy entitled Administering Medications last reviewed by the facility on January 24, 2024, indicated that insulin pens will be clearly labeled with the resident's name or other identifying information. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. An observation of a first floor medication cart on October 24, 2024, at 9:07 a.m., revealed Employee 9 LPN (license practical nurse) was working medication cart. One Basaglar insulin pen, two Lispro insulin pens, and one Humulin 70/30 insulin pen were opened and available for use. There was no evidence that the insulin pens were dated when opened or with an expiration/beyond use date. Further observations of the first floor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, payor source data, and staff interview, it was determined the facility failed to offer routine annual dental services for one resident with Medicaid as a payor source (Resident 52) and failed to promptly refer a resident with mouth pain and a physician's order for a dental consult with Medicaid as a payor source (Resident 86) out of 20 residents sampled Findings include: Review of Resident 52's clinical record revealed admission to the facility on November 2, 2023, and the resident's current payor source was Medicaid. There was no documented evidence at the time of the survey ending October 25, 2024, the resident had been offered dental services in the past year. Review of resident 86's clinical record revealed admission to the facility on June 14, 2024, and the resident's current payor source was Medicaid. A physician's order dated August 1, 2024, revealed on order for a dental consult for left side mouth pain. At the time of the survey ending October 25, 2024, the facility was unable to provide documented evidence the facility had provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control policies and procedures and staff interview, it was determined the facility failed to implement an antibiotic stewardship program for 6 of 12 months reviewed. (April 2024-September 2024). Findings include: Review of the facility policy entitled Antibiotic Stewardship last reviewed January 2024 indicated antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of the antibiotic stewardship program is to monitor the use of antibiotics in the residents. Review of the facility's Infection Control surveillance for September 2023 through September 2024, failed to include documentation to indicate that antibiotic monitoring was completed for 6 months (April 2024 through September 2024). During an interview on October 25, 2024, at 9:45 a.m. the Director of Nursing confirmed the facility failed to implement an antibiotic stewardship program that included a system of surveillance to monitor antibiotic use and laboratory correlation for infections for 6 of 12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff interview, it was determined the facility failed to provide meal service in an environment that maintains each resident's dignity for one of 20 sampled residents (Resident 42). Findings include: Review of Resident 42's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including unspecified dementia. Observation of the third floor nursing unit on October 22, 2024, at approximately 12:20 p.m. revealed Resident 42 was in the dining room. Resident 42's lunch tray was placed in front of her on the table at approximately 12:22 p.m. Resident 42 required assistance with feeding and was unable to feed herself. Further observation revealed that Resident 42 was not assisted with her lunch meal until approximately 12:47 p.m. approximately 25 minutes after it was placed in front of her. Interview with the Nursing Home Administrator on October 22, 2024, at approximately 1:45 p.m. confirmed that Resident 42 should have been served…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the Resident Assessment Instrument, and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments accurately reflected the status of one resident out of 20 sampled (Resident 94). Findings include: A review of the clinical record of Resident 94 revealed a physician's order dated August 2, 2024, for the resident to be discharged to home on August 6, 2024. A review of a nurses note dated August 6, 2024, at 11:53 AM revealed that Resident 94 was discharged home via facility transport. The resident was able to walk independently. Discharge instructions provided to the resident. All discharge paperwork was signed by the resident. Medications, prescriptions, and education provided. All personal belongings brought home. Resident not in any form of distress and in good spirits. A review of Resident 94's Discharge MDS Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 6, 2024, Section A 2105, indicated that 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 observation, clinical record review and staff interview, it was determined the facility failed to develop and implement a person-centered comprehensive care plan to meet the needs of three out of 20 residents sampled (Residents 86, 28, and 13) Findings including: Clinical record review revealed that Resident 86 was admitted to the facility on [DATE], with diagnoses to include hypertension (elevated blood pressure), Type 2 diabetes (body has trouble controlling blood sugar and using it for energy), and hyperlipidemia (high cholesterol). A review of Resident 86's hospital records sent to the facility on June 13, 2024, revealed the resident underwent a pacemaker placement (device implanted in the body to deliver electrical impulses to the heart to help the heartbeat at a normal rate and rhythm) on June 15, 2022. A review of chest x-ray results dated June 12, 2024, confirmed the placement of the pacemaker device. A physician's order dated August 1, 2024, revealed on order for the resident to see 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, observation, and resident and staff interviews, it was determined the facility failed to ensure a resident's comprehensive care plan was reviewed and revised as needed to accurately reflect the resident's current needs and services required by one of 20 residents reviewed (Resident 22). Findings include: Review of the clinical record of Resident 22 revealed initial admission to the facility on May 11, 2019, with diagnoses to include congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), stroke, and anxiety. A review of Resident 22's Elopement/Wander Risk Evaluation dated May 21, 2024, revealed that the resident was a low wander risk as indicated by a score of 1 (a score of 0-4 indicated low risk for wandering/elopement). Review of Resident 22's current physician orders revealed an order dated September 18, 2024, which permitted the resident to go out on pass by himself via the bus. A review of a quarterly Minimum Data Set Assessment (MDS - federally mandated assessment of 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 a review of clinical records and staff interviews it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses administered medications as prescribed to one resident of 20 sampled residents (Resident 22) 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 collect complete 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. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical records, and staff interview it was determined the facility failed to monitor the nutritional parameters for one resident with an identified significant weight loss out of 20 residents sampled (Resident 60). Findings include: Review of a facility policy titled Weight Assessment last reviewed by the facility in January 2024, revealed that any weight change of 5 pounds or more since the last assessment will be retaken for confirmation. If the weight loss is verified nursing will notify the physician and dietician. A review of Resident 60's clinical record revealed admission to the facility on December 16, 2021, with diagnoses to include dementia (the loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). A review of the resident's weights noted the following: July 1, 2024 125.0 lbs August 2, 2024 122.0 lbs September 4, 2024 117.0 lbs September 10, 2024 114.0 lbs indicating a 6.6% weight loss in 30 days. The dietician requested a reweight after the five pound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, and resident and staff interview it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for a resident receiving hemodialysis for one of 20 residents sampled. (Resident 85) Findings include: According to the National Kidney Foundation patients receiving hemodialysis (a machine filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) should keep emergency care supplies on hand. A review of Resident 85's clinical record revealed the resident was admitted to the facility was on August 11, 2024, with diagnoses that included end stage renal disease (a chronic kidney disease that occurs when the kidneys can no longer function properly) and dependence on renal hemodialysis. A review of the resident's current plan of care dated August 15, 2024, and last revised August 27, 2024, revealed that the resident required dialysis with the potential for infection, fluid volume excess/deficit, pain, and trauma related to end stage renal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined the facility failed to ensure each resident received the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one of 20 residents sampled (Resident 10). Findings include: A review of Resident 10's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania). Further review of Resident 10's clinical record revealed the resident exhibited behaviors, including agitation, restlessness, crying and yelling out. Observations on October 22, 2024, between 8:45 a.m. and 9:30 a.m., revealed Resident 10 to be wheeling in and out of her room appearing restless and agitated. 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 observations and staff and resident interview, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment in resident areas on three of three resident units (First, Second, and Third Floor Nursing Units) Findings include: Observations on October 11, 2023, at 9:30 AM on the First Floor Nursing Unit in room [ROOM NUMBER] revealed multiple dried brown spots on the walls. A dried brown substance was observed on the outside the door on the door frame. The molding in the room was stained with black marks. There was a hole observed in the wall by the molding and another hole in the wall behind bed 1. In resident room [ROOM NUMBER] the walls were scuffed, cracked, and multiple dried brown spots were observed. Dried brown spots were observed on the molding. The molding around the door was peeling. Dirt, debris, and food particles were observed on the floor. A dried crusty brown substance was observed behind bed 2 and the drywall was damaged. In…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined the facility failed to provide clean mattresses, bed frames and functional furniture in resident rooms on three of three nursing units (First, Second, and Third Floor). Findings include: A tour of the facility's First Floor Nursing Unit on October 11, 2023, at 9:30 AM revealed in resident room [ROOM NUMBER] the bed frame of bed#2 was coated with an unknown dried substance and brown spots covering the bed frame. The fall mats next to bed were ripped and torn. A tour of the facility's Second Floor Nursing Unit on October 11, 2023, at 9:45 AM revealed in resident room [ROOM NUMBER] the mattress was cracked and flaking. Dried spots, stains, dirt and debris were observed on the bed frame. The mattress in resident room room [ROOM NUMBER] was dirty and an unknown dried substance and brown spots covering the bed frame. A tour of the facility's Third Floor Nursing Unit on October 11, 2023, at 10:08 AM revealed in the dressers in resident room [ROOM NUMBER] were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and select resident incident/accident reports and staff interview, it was determined that the facility failed to consistently provide necessary supervision and effective safety measures to prevent repeated falls for a resident identified at high risk for falls and known unsafe behaviors, for one resident out of five sampled (Resident 2). Findings include: A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses of diabetes, anxiety, nontraumatic chronic subdural hemorrhage and history of falling. A review of a significant change Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated April 28, 2023, revealed that the resident was moderately cognitively impaired with a BIMS score of 10 (BIMS (Brief Interview for Mental Status) is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into 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 a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of five sampled (Residents 2). Findings include: According to the RAI User's Manual, Section J1700, Fall history on admission/entry/reentry Assessment (OBRA or Scheduled PPS), the facility is to record a fall in the past month prior to admission /entry or reentry. A review of Resident 2's significant change MDS assessment dated [DATE], indicated that the resident did not have have a fall in the last month prior to admission/entry or reentry. However, a review of the resident's clinical record documentation indicated that the resident had a fall on March 27, 2023. According to the RAI User's Manual, Section J1700 , Fall history on admission/entry/reentry Assessment (OBRA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 individualized care instructions for the resident's plans for care after discharge for one of two discharged residents reviewed (Resident 1) Findings include: A review of the closed clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses including colon cancer, sacral ulcer and muscle weakness. Resident 1 was discharged home on August 22, 2023. A review of Resident 1's clinical record, conducted during the survey ending September 7, 2023, revealed a Discharge Record form dated August 18, 2023, which included the resident's admitting diagnosis as pressure ulcer, sacral region, stage 4. A Discharge Summary form dated August 18, 2023, noted the reason for the resident's discharge as completed therapy and skilled care. In the section Social Services, question 8. indicated to List any follow up appointments scheduled, include name and speciality. The resident's attending…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff interviews it was determined that the facility failed to ensure that the resident's drug regimen was free of unnecessary antibiotic drugs for one out of five residents sampled (Resident 1). Findings included: A review of Resident 1's clinical record revealed a physician order dated August 15, 2023, to obtain a urinalysis and culture and sensitivity to rule out urinary tract infection. A review of a laboratory report for a urinalysis dated August 16, 2023, revealed the results as abnormal with blood, protein and bacteria in the sample. A physician's order dated August 16, 2023, was noted for Cephalexin 500 mg (an antibiotic medication) by mouth every 12 hours for 7 days for urinary tract infection. There was no physician/prescribed documentation of the clinical necessity of initiating antibiotic therapy prior to the results of the culture and sensitivity. A review of the resident's medication administration record for the month of August 2023, revealed that the resident received 13 doses of Cephalexin medication prior to her discharge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and the facility's infection prevention and control program and staff interview it was determined that the facility failed to maintain an antibiotic stewardship program that includes a system to effectively monitor antibiotic usage as evidenced by one of five sampled residents (Resident 1). Findings include: A review of the facility policy for Antibiotic Stewardship, dated as reviewed July 2023, revealed that to reduce a resident's risk of adverse drug reactions and preserve drug efficacy in the face of rising multi-drug resistant pathogens, the facility: -Ensures staff expertise to develop and manage the antibiotic stewardship program, improve antibiotic use and the frequency with which they are used, with a commitment to quality improvement. -Educate staff on the importance of appropriate antibiotic use, and implementing strategies to optimize the use of antibiotics. -monitors antibiotic prescribing-Antibiotic stewardship measurement is critical to identify opportunities for improvement and assess the impact of improvement efforts. A 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.