Broad Mountain Health And Rehabilitation Center

Based on observations, review of clinical records, review of select facility policies, review of job descriptions, documentation provided by the facility, and interviews with residents and staff, it was determined the facility's administration failed to effectively use its resources to ensure resident safety and maintain the highest practicable physical and mental well-being of residents. The facility failed to ensure that measures were implemented to prevent one of twelve residents identified as being at risk for wandering (Resident 1) from exiting the building unattended into an unsafe environment. This deficient practice placed all residents at risk for harm and resulted in immediate jeopardy to residents' health and safety.Findings include:A review of the job description for the Nursing Home Administrator (NHA) dated and signed September 12, 2024, indicated the administrator will lead and manage the overall operations of the facility in accordance with policies, procedures, and current federal, state, and local standards, guidelines, and regulations. The NHA's essential duties…

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 abuse prohibition policy, clinical records, information submitted by the facility, and select investigative reports and staff interview, it was determined the facility failed to assure that three residents (Residents 2,3, and 4) out of 3 sampled were free from physical abuse perpetrated by another resident (Resident 1). Findings include: A review of facility policy titled Pennsylvania Resident Abuse: Abuse, Neglect, and Exploitation last reviewed by the facility on May 2025, revealed it is the policy of the facility not to tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A separate…

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

Based on observations, a review of clinical records, and resident and staff interviews, it was determined the facility failed to reasonably accommodate residents' need for call bell accessibility for four out of 30 residents sampled (Residents 35, 77, 75, and 83) and to ensure the accessibility of resident room display boards as expressed by 2 out of 6 residents during a resident group interview (Residents 24 and 45). Findings include: Observation on April 8, 2025, at 10:41 AM in resident room revealed that Resident 77 and Resident 75 were in their respective beds and unable to reach or access their call bells to summon staff assistance if needed. The call bells for both residents were observed on the floor, behind the head of the bed, and out of the residents' reach. Observation on April 8, 2025, at 10:50 AM revealed Resident 35 seated in a wheelchair along the right side of his bed in his room. The resident's call bell was on the floor on the left side of the bed, behind the headboard, and out of the resident's reach. During an interview at the time of the observation, Resident 35…

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 select facility policy, observations, and resident and staff interview it was determined the facility failed to ensure that a resident dependent on staff for assistance with activities of daily living (ADLs) consistently was provided showers as planned to maintain good personal hygiene and failed to provide a resident dependent on staff for ADLs, the necessary services to maintain good nutrition for two residents out of 30 sampled (Residents 35 and 103). Findings include: A review of Resident 35's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include cerebral infarction (a stroke caused by a blockage of blood flow to the brain, leading to tissue damage and potential cell death), and type 2 diabetes (trouble controlling blood sugar and using it for energy) with diabetic neuropathy (nerve damage caused by long-term high blood sugar levels). A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized…

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 and a review of employee personnel records it was determined the facility failed to ensure the qualified part-time professional activities director responsibilities included directing the development, implementation, supervision and ongoing evaluation of the activities program, which includes the completion and/or directing/delegating the completion of the activities component of the comprehensive assessment; and contributing to and/or directing/delegating the contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident. Findings include: Interview with the administrator on April 11, 2025, at approximately 10:00 AM revealed that the previous full-time qualified activities director resigned on September 20, 2024. The administrator stated that a qualified activities director from a sister facility was assisting with coverage until December 6, 2024. Since December 6, 2024, Employee 5 (activities director) has been the activity director with remote oversight…

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 resident and staff interviews, it was determined the facility failed to provide person-centered care for diabetes management and professional standards of practice for one resident out of 30 sampled (Resident 45). Findings include: A review of facility policy entitled Diabetic Protocol, last reviewed on March 20, 2025, indicated the provider and staff will work together to give appropriate treatment to manage diabetes, and for residents who have or are suspected to have diabetes, the provider will order pertinent testing. A review of the clinical record revealed Resident 45 was admitted to the facility on [DATE], with diagnoses to include diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of sugar in the blood and urine) and end-stage renal disease dependent on dialysis (the process of removing waste products and excess fluid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to ensure that pain management is provided to residents consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one resident out of 30 sampled (Resident 36). Findings include: A review of the facility policy titled Pain Management Policy, last reviewed by the facility on March 20, 2025, revealed it is the facility policy to ensure any resident admitted to the facility is assessed for pain and potential for pain in order for the resident to reach and maintain his or her highest practicable level of physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The policy indicated a pain evaluation will occur with an onset of new pain. The evaluation will include the presence of indicators of pain or active pain, including type, intensity,…

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 select facility policy and staff interviews, it was determined the facility failed to implement procedures for smoking safety, as evidenced by three out of the three residents sampled for smoking.(Residents 45, 51, and 79). Findings include: A review of the facility policy titled Resident Smoking Policy, last reviewed by the facility on March 20, 2025, revealed it is the facility policy to establish resident smoking processes that take into account both smoking and non-smoking residents and that comply with applicable federal, state, and local laws and regulations regarding smoking, smoking areas, and smoking safety. The policy indicated any resident that chooses to smoke will be further assessed for smoking safety awareness and the need for reasonable physical or safety accommodations. The assessment is completed thereafter on readmission, quarterly, and with any significant change in the resident's condition. A clinical record review of Resident 45 revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, the Resident Assessment Instrument (RAI), and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments accurately reflected the status of one resident out of 30 sampled (Resident 106). 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 A2105: Discharge Status indicates to review the medical record, including the discharge plan and discharge orders, for documentation of discharge location. A clinical record review revealed Resident 106 was admitted to the facility on [DATE], and discharged on January 22, 2025. A review of the discharge return not anticipated…

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 ensure that a resident's comprehensive care plan was reviewed and revised as needed to accurately reflect their current needs and services required by one of 30 residents sampled (Resident 101). Findings include: A clinical record review revealed Resident 101 was admitted to the facility on [DATE], with diagnoses to include bipolar disorder (a condition characterized by periodic, intense emotional states affecting a person's mood) and diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces). A review of Resident 101's psychiatric consult dated March 18, 2025, at 1:22 PM indicated the assessment and plan included monitoring and documenting any signs of depression, anxiety, mood swings, paranoia, hallucinations, delusions, irritability, lack of motivation, and changes in sleep or appetite. A review of Resident 101'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 a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals for one out of the 30 residents sampled (Resident 36). Findings include: A review of the facility policy titled Discharge Planning Process, reviewed by the facility on March 20, 2025, revealed it is the facility's policy that when a resident's discharge is anticipated, the facility will develop and implement a discharge plan that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge, and the reduction of factors leading to preventable readmissions. The policy indicates if the resident is interested in returning to the community, then the facility will document any referrals to local contact agencies or other appropriate entities made for this purpose. If the discharge to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interviews it was determined the facility failed to ensure a resident's drug regimen was free of unnecessary antibiotic drugs for one out of 30 residents sampled (Resident 105). Findings include: A review of the clinical record revealed Resident 105 was admitted to the facility on [DATE], with diagnoses to include multiple sclerosis (disease in which the immune system eats away at the protective covering of the nerves), chronic obstructive pulmonary disease (COPD- group of lung diseases that block airflow and make it difficult to breathe), and dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of a nurse's note dated February 22, 2025, at 8:35 AM, indicated Resident 105 was assessed following staff reports of labored breathing. The note documented the resident was lethargic, responsive to verbal stimuli but quickly fell back asleep.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy, clinical records and staff interviews it was determined the facility failed to timely notify the physician of abnormal lab results for one resident out of 30 sampled (Resident 96). Findings included: A review of facility policy entitled Resident Change in Condition Policy, last reviewed on March 20, 2025, indicated that nursing will recognize and intervene in the event of a change in resident condition and the physician and family/responsible party will be notified as soon as the nurse has identified the change in condition, including the most recent labs. A review of the clinical record revealed that Resident 96 was admitted to the facility on [DATE], and had diagnoses that include diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and malignant neoplasm of the brain (a cancerous growth in the brain that typically grows rapidly, invades surrounding brain…

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, payor source data, and resident and staff interview, it was determined the facility failed to provide timely and necessary dental services for one resident who is a Medicaid recipient (Resident 35) out of 30 residents reviewed. Findings included: A review of Resident 35's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include cerebral infarction (a stroke caused by a blockage of blood flow to the brain, leading to tissue damage and potential cell death), and type 2 diabetes (trouble controlling blood sugar and using it for energy) with diabetic neuropathy (nerve damage caused by long-term high blood sugar levels). A quarterly Minimum Data Set Assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 2, 2025, indicated the resident was cognitively intact with a BIMS score of 15 (brief interview for mental status, a tool to assess the residents'…

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

Based on a review of Food Committee Minutes (completed in addition to Resident Council meetings) and resident and staff interviews, it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during resident group meetings, including those voiced by three of the six residents interviewed during a group interview (Residents 32, 62, and 69) and one resident out of the 20 sampled (Resident 54). Findings include: A review of minutes from Food Committee meeting dated March 20, 2024, with 12 residents in attendance, revealed that residents brought up a concern that they were not being provided snacks prepared by the baker and a choice or variety of snacks were not being provided by the facility. A review of minutes from Food Committee meeting dated April 22, 2024, with 7 residents in attendance, revealed that residents brought up a concern that nighttime were not being offered. During a resident group interview on May 8, 2024, at 10:00 AM, three of the six residents in attendance (Residents 32, 62,…

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 Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 20 sampled (Residents 7 and 13). Findings include: According to the RAI User's Manual dated October 2023, Section A 1500 Preadmission Screening and Resident Review (PASRR) is to be completed if the type of assessment is an admission assessment, significant change, or annual assessment. The annual MDS Assessment of Resident 7 dated October 1, 2023, revealed Section A 1500 was coded as 0, indicating that the resident was not considered by the state to require a Level II PASRR process, to have serious mental illness, and/or intellectual disability, mental retardation, or a related condition. A review of Resident 7's clinical record revealed that a Level I PASRR was completed on March 7, 2018, indicating that the resident met the criteria for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy and clinical records and staff interview it was determined that the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for bowel protocol for two residents out 20 sampled (Residents 89 and 50) to promote normal bowel activity to the extent possible Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine} the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). The facility policy titled Bowel Tracking Protocol, last reviewed by the facility, March 24, 2024, indicated the facility will record and monitor bowel activity of residents each shift and address issues identified. In the absence 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 clinical record review and resident and staff interviews, it was determined the facility failed to provide therapeutic social services to promote the highest practicable mental and psychosocial well-being of two of the 20 residents reviewed (Residents 46 and 54). Findings include: According to regulatory guidance under §483.40(d) Medically-related social services means services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health, which include providing or arranging for needed mental and psychosocial counseling services and identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident. A clinical record review revealed Resident 46 was admitted to the facility on [DATE], with diagnoses that include cerebral infarction (brain damage that results from a lack of blood), major depressive disorder (a mental health disorder characterized by a persistently low 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.

Based on observation, a review of select facility policy and clinical records, and staff interviews, it was determined that the facility failed to adhere to acceptable storage and use by dates for multi-dose medication and herbal supplements on one of three medication carts and one of three medication storage rooms observed (west short cart, first floor storage room - Residents 9, and 77). Findings include: The facility policy Storage and Expiration Dating of Medications, Biologicals, with a policy review date March 24, 2024, indicated that facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Observation of [NAME] Short medication cart at approximately 9:13 AM, on May 7, 2024, in the presence of Employee 4,…

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 facility's smoking policy and staff interview, it was determined that the facility failed to implement established procedures to accurately assess residents for safe smoking ability for three residents out of three identified as a current smoker (Resident 50, 54, and 58). Findings include: A review of the facility's policy titled Resident Smoking Policy last reviewed by the facility March 24, 2024, indicated that a smoking assessment would be completed with readmission, quarterly and with any significant change in resident's condition. During entrance conference meeting on May 7, 2024, at 9:18 AM the Nursing Home Administrator (NHA) provided a list of residents at the facility that currently smoke, which included three residents, Resident 50, 54, and 58. Review of Resident 50's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include diabetes and depression. The most recently completed quarterly smoking 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 clinical record review and staff interview, it was determined that the facility failed to accurately complete the PASRR (Preadmission Screening and Resident Review) according to the resident assessment for one of six residents reviewed related to PASRR assessments (Resident 58). Findings include: The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level 1 PASRR determined that the person is a targeted person with mental illness or an intellectual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 20 residents reviewed (Resident 58). Findings include: A review of the clinical record revealed that Resident 58 was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD). The resident's current care plan, in effect at the time of review on May 10, 2024, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. The facility failed to develop and implement an individualized person-centered plan to address, this resident's diagnosis of PTSD according to standards of practice to promote the resident's emotional well-being and safety. Interview with 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 review clinical records and resident and staff interviews it was determined that the facility failed to provide care in a manner and environment, which promotes each resident's quality of life by failing to respond timely to residents' request for assistance as evidenced by experiences reported by seven residents out of 15 interviewed (Residents 8, 21, 22, 23, 73, 74, and 102). Findings include: A review of resident clinical record and a facility provided BIMS (brief interview mental status - a tool that assesses cognitive status) report and random interviews conducted on October 17, 2023, with 15 alert and oriented residents, to include 8 residents residing on the 100 unit, and 7 residents residing on the 300 unit, revealed that 7 residents' interviews voiced concerns regarding staff's failure to respond to their requests for assistance and provide needed care and services in a timely manner. During interviews, the residents relayed that they feel the facility is not adequately staffed because they wait extended periods of time for staff to respond to their requests 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 observation, resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment on three of the three nursing units (Nursing Units 1, 2 and 3). Findings include: During an environmental tour of the facility on October 17, 2023, at approximately 2:35 PM, the front face panel of the heating unit located in resident room [ROOM NUMBER] was off the unit and on the floor, resting against the unit, exposing the inner workings, coils with surrounding aluminum fins and electrical wiring. Interview with Employee 1, Licensed Practical Nurse (LPN), on October 17, 2023, at approximately 2:40 PM, stated that the panel came off in the recent past, and is known to happen. Employee 1 stated that resident passes by the heating unit with her wheelchair and hits the unit and the face panel falls off. Staff then notifies maintenance staff to reapply the face panel to the unit. An observation on October 17, 2023, at 9:10 AM 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 observations, facility provided documents and staff interview, it was determined that the facility failed to maintain an effective pest control program. Findings include: An observation on October 17, 2023, at 9:00 AM in resident room [ROOM NUMBER] revealed flying insects on the side wall of the resident bathroom and flying about the room. An observation on October 17, 2023, at 9:10 AM in resident room [ROOM NUMBER] revealed a cylindrical standing fly trap with several flies attached and free-flying insects flying around the trap. Flies were also observed on the window-side bed, on the resident privacy curtains, on the window-side wall, and on the resident's television. An observation on October 17, 2023, at 9:30 AM of resident room [ROOM NUMBER] revealed a white fly trap with flies adhered inside. Flies were observed on the windowsill and flying about the room. An observation on October 17, 2023, at 11:00 AM revealed flies in the Unit 1 hallway outside of the facility conference room. 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.

Based on test tray results and resident and staff interview, it was determined that the facility failed to serve foods at palatable temperatures. Findings include: According to the federal regulation 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. Random interviews with residents during the survey of September 8, 2023, revealed that six cognitively intact residents, (Residents 10, 43, 60, 68, 94, and 98) voiced concerns that the food is not served at palatable temperatures. Resident 10 stated that cold foods are served warm and hot foods are served cold. Resident 43 stated that hot foods are served cold, stating soup is always cold, coffee is cold. Resident 60 stated that the hot food is served cold. Resident 68 relayed that hot food is served cold and the cold food is warm. The resident stated that the milk for cereal is warm, jello was liquid. Resident 94…

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 and select incident report review and staff interview, it was determined the facility failed to implement interventions planned on the comprehensive care plan for preferred diversional activities to promote resident safety and deter falls for one resident out of four sampled (Resident 1). Findings include: A review of the clinical record of Resident 1 revealed admission to the facility on March 31, 2023, with diagnoses, which included abnormality of gait (manner of walking) and mobility, lack of coordination, and dementia (the loss of cognitive functioning {thinking, remembering, and reasoning} to such an extent that it interferes with a person's daily life and activities). An admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated April 5, 2023, revealed that the resident was severely cognitively impaired. A nurses note dated April 2, 2023, at 1:19 PM revealed that the resident was trashing his room. Nursing noted that the resident was opening, and closing…

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 interviews it was determined that the facility failed to develop and implement individualized pain management programs, consistent with professional standards of practice and follow physician orders when administering pain medication for one of four residents reviewed (Resident 1). Findings include: According to the US Department of Health and Human Services, Interagency Task Force, Executive Summary Final Report May 6, 2021, for Pain Management Best Practices the development of an effective pain treatment plan after proper evaluation to establish a diagnosis with measurable outcomes that focus on improvements including quality of life (QOL), improved functionality, and Activities of Daily Living (ADLs). Achieving excellence in acute and chronic pain care depends on the following: · An emphasis on an individualized patient-centered approach for diagnosis and treatment of pain is essential to establishing a therapeutic alliance between patient and clinician. · Acute…

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 controlled drug medication sheets, and staff interview, it was determined that the facility failed to implement procedures to promote accurate accounting of controlled medications for one of four residents sampled (Resident 1). Findings include: A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with a compression fracture of the lumbar vertebrae. Resident 1 had a physician order initially dated April 4,2023 for Oxycodone HCL (a narcotic opioid pain medication) 5 mg tablet every 4 hours as needed for pain level 4 to 10. A review of the controlled medication record accounting for the above narcotic medication revealed that on April 4, 2023, at 11:30 PM, April 5, 2023, at 4:00 AM, April 6, 2023, at 2:30 AM and 6:30 AM, April 8, 2023, at 11:30 PM, and April 14, 2023, at 12:00 AM and 4:00 AM nursing signed out a dose of the resident's supply of Oxycodone 5 mg. However, the administration of the controlled drug to the resident was not…

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 that the facility failed to ensure that medications were labeled according to accepted labeling requirements for two of five residents sampled (Resident 54, and 95). Findings include: A review of Resident 54's clinical record revealed she was most recently admitted to the facility on [DATE], with diagnoses of non-traumatic intracerebral hemorrhage, diabetes, protein-calorie malnutrition, and gastro-esophageal reflux disease (GERD). A physician order dated [DATE], was noted Oxycodone - Acetaminophen (an opioid pain medication) 5-325 milligram (mg), give 1 tablet by mouth two times a day for pain, and give 1 tablet by mouth every 6 hours as needed for break through pain, severe 7-10, for 14 days. A controlled medication utilization record was labeled with Resident 54's name, and the medication Oxycodone - Acetaminophen 5-325 mg, dated [DATE], noting one tablet by mouth three times dailyroutine chronic pain. A line was drawn…

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 plan of correction from the survey ending September 8, 2023, and the outcome of the activities of the facility's quality assurance committee it was determined that the facility failed to develop and implement a quality assurance plan, which was able to identify and correct ongoing quality deficiencies related implementing procedures to promote accurate accounting of controlled medications for one of five residents sampled (Resident 54). Findings include: As a result of the deficiencies cited under the requirements related to pharmacy procedures - records, during the survey of September 8, 2023, the facility developed a plan of correction to serve as their allegation of compliance, which included a quality assurance monitoring component to ensure that solutions were sustained. This corrective plan was to be completed and functional by September 20, 2023. However, during the survey ending September 27, 2023, continuing deficient facility practice was identified with this same requirement. According to the facility's plan 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.