Saint Anne Home

Based on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent. Findings include: Observations during medication administration on June 25, 2025, revealed that two medication administration errors were made during 35 opportunities for error, resulting in a medication administration error rate of 5.71 percent. Current manufacturer's directions for use of Metoprolol Extended Release (ER) (used to treat high blood pressure, heart failure, and chest pain) revealed that it is preferable to administer with or immediately following meals; however, may administer without regards to meals. May divide tablets in half; do not crush or chew. Crushing modified release dosage forms (e.g., ER tablets) may result in release of excessive doses, variable serum concentrations, and risk of severe adverse effects including fatalities. Physician's orders for Resident 111, dated November 7, 2024, included an order for the resident to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies, manufacturer's directions for use, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to label multi-dose containers of insulin with the date they were opened in one of four medication carts reviewed (Villa [NAME] Garden medication cart), and failed to discard an expired bottle of testing solution for one of four medication room refrigerators reviewed (Villa [NAME] Garden medication room refrigerator). Findings include: The facility's policy regarding medication storage, dated [DATE], revealed that medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity, and to support safe, effective drug administration. Outdated, contaminated, discontinued or deteriorated medications and those containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. 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 of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) surveys ending June 13, 2024; October 22, 2024; and April 21, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending June 18, 2025, identified repeated deficiencies related to failure to provide confidentiality of residents' personal health information, failure to ensure that MDS assessments were accurate, care plan timing and revision, issues with urinary catheters, maintaining a medication error rate below 5 percent,…

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 maintain the reach-in refrigerator in proper working condition in the Main Kitchen. Findings include: Observations in the dietary department's reach-in refrigerator on June 25, 2025, at 11:51 a.m. revealed that the rubber gasket at the bottom of the door was loose and hanging down, and the door would not close easily. Interview with the Chef Manager at that time confirmed that the refrigerator door's rubber gasket was loose and hanging, and should have been repaired. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of eights residents reviewed (Resident 2). Findings include: The facility's policy for abuse, dated October 10, 2024, indicated that the facility forbids and prohibits the mistreatment, neglect, verbal, mental, physical or sexual abuse of residents. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 19, 2025, revealed that the resident was understood, could understand, was cognitively intact, and had diagnoses that included Parkinson's Disease (a medical condition that affects movement). A nursing note for Resident 2, dated May 8, 2025, at 7:04 p.m., revealed that the resident had a coughing episode after medication administration. His lungs were decreased in all lobes and vital signs taken were temperature of 97.6, pulse of 97 beats per minute, respirations at 18 breaths per minute,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and information provided by the facility, as well as observations and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures. Findings include: The facility's policy regarding taste and temperature control, dated October 10, 2024, revealed that prior to the start of each meal period, there is an evaluation of the taste and temperature of food. Cold foods, such as milk, butter, ice cream, and juices are refrigerated during service or properly iced. Holding temperatures for hot foods will be 140 degrees Fahrenheit (F) or above. Holding temperatures for cold foods will be 40 degrees F or below. All foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit (F) (or as state regulation requires) for hot holding and less than 41 degrees F for cold food holding. Review of Resident Council meeting minutes, dated October 2024, revealed that the residents on the Villa [NAME] Unit complained about their food…

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 job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume responsibility for effective management of the facility to ensure that the facility operated in compliance with state regulations and codes by not ensuring that hot liquids were served at appropriate temperatures, without which the residents health and safety are jeopardized for two of five residents reviewed (Resident R2, R5). Findings include: The job description for the NHA, dated May 4, 2021, indicated that the DON is to direct the functions of the Nursing Department in the delivery of care to residents according to accepted professional standards and in accordance with St. [NAME] Home's ethical requirements as described in our Mission, Vision, Value, Pledge and Fundamental Commitment statements found in the Code of Corporate Compliance. The NHA must meet all standards of performance and adhere to all…

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

Based on review of clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that staff immediately reported a fall with injury for one of seven residents reviewed (Resident 1). Findings Include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 9, 2024, revealed that the resident was cognitively impaired, required assistance with care needs, was dependent for transfers, and had diagnoses that included Alzheimer's disease and osteoporosis (condition that weakens the bones and increases risk for fracture). The current activities of daily living care plan for Resident 1 indicated that the resident required the use of a mechanical lift for transfers. Investigation documentation provided by the facility revealed that Nurse Aide 1 (an agency nurse aide) called the facility on August 6, 2024, and reported to Registered Nurse 3 that a fall occurred on August 5, 2024, involving Resident 1. Nurse Aide 1 reported that she went into…

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

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for seven of 48 residents reviewed (Residents 3, 7, 26, 30, 64, 66, 73). Findings include: The facility policy for care plans, dated October 13, 2024, indicated that care plans are to reviewed/rewritten/revised quarterly and/or on an ongoing basis to reflect the changes in the resident and the care that the resident is receiving. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated July 3, 2024, revealed that the resident was cognitively impaired, was clearly understood and able to understand others, required assistance with care needs, was receiving antianxiety and antipsychotic medications, and had diagnoses that included depression, anxiety, and dementia. Physician's order for Resident 3, dated April 2, 2024, indicated that the resident was ordered five milligrams (mg) 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for four of 48 residents reviewed (Residents 43, 58, 65, 125). Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 43, dated April 17, 2024, revealed that the resident was cognitively impaired, required extensive assistance for daily care needs, and had diagnoses that coronary artery disease, hypertension (high blood pressure), and was on Eliquis (a medication to prevent blood clots). The resident's care plan, dated April 11, 2024, indicated that the resident was to be assessed for alterations in skin conditions and bleeding. Physician's orders for Resident 43, dated April 11, 2024, included an order for the physician to be notified of side effects of Eliquis such as bruising, bleeding, or complications. A nursing note for Resident 43, dated May 28, 2024, at 9:31 a.m., revealed that staff observed a new bruise to the resident's right arm. There…

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

Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure a medication error rate of less than five percent. Findings include: Observations during medication administration on July 24, 2024, at 9:59 a.m. revealed that eight medication administration errors were made during 28 opportunities for error, resulting in an error rate of 28.57 percent. Current physician's orders for Resident 12 included orders for the resident to receive 35 milliliters (ml) of Valproic acid 250 milligram (mg)/5 ml oral solution twice a day by mouth for a seizure disorder; 30 ml of Lactulose 220 grams/30 ml oral solution (a medicine used as a laxative) twice a day via gastric tube; 1 mg of Klonopin (a medicine used as a sedative) twice a day via gastric tube (tube inserted through the belly that brings nutrition or medication directly to the stomach) for profound mental retardation with agitation; 1 mg of Risperdal (a medicine used as an antipsychotic) twice a day via gastric tube for profound mental deficiency secondary to mental…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to determine if residents were safe to self-administer medications for one of 48 residents reviewed (Resident 58). Findings include: The facility's self-administration of medications policy, dated October 13, 2023, indicated that if a resident desired to self-administer medications, they would require a physician's order. The facility's medication administration policy, dated October 13, 2023, indicated that the nurse must stay with the resident until the medication is taken. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58, dated June 14, 2024, indicated that the resident was cognitively intact and required extensive assistance from staff with care. Current physician's orders included an order for the resident to receive a 100 mg tablet of Colace (a medication to treat constipation) twice a day; 5 mg of Eliquis (a blood thinning medication), 1 tablet in the a.m.; 800 mg…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or resident representative had an opportunity to develop an advance directive or assist in formulating an advance directive for three of 48 residents reviewed (Residents 3, 7, 55). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated July 3, 2024, revealed that the resident was cognitively impaired, was understood and able to understand others, required assistance with care needs, and had a diagnosis of dementia. A review of the resident's clinical record revealed no evidence that the resident or their representative was informed of their rights to develop advance directives and no documented evidence that they were provided an opportunity and assistance to formulate one if they chose to do so. A significant change MDS assessment for Resident 7, dated May 26, 2024, revealed that the resident was cognitively impaired, was usually understood and…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage or a 48-hour advanced notice for one of three residents reviewed (Resident 122). Findings include: A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility and dated July 23, 2024, revealed that Medicare coverage for Resident 122 started on April 21, 2024, and that her last covered day was May 8, 2024. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. The form was signed by the resident on May 6, 2024. The facility had no documented evidence that the resident was issued a SNF Beneficiary Protection Notification form or an Advanced Beneficiary Notice (ABN) notice as required. Interview with Social Worker on July 24, 2024, at 2:28 p.m. confirmed that Resident 122 did not have an ABN completed timely. She forgot to…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for one of 48 residents reviewed (Resident 137). Findings include: The facility policy regarding privacy of health information, dated October 13, 2023, indicated that the resident's health information needs to remain private. Observations during medication administration on July 25, 2024, at 8:27 a.m. revealed that Licensed Practical Nurse 1 walked away from the medication cart to assist Resident 137 with something. Resident 137's personal health information was visible on the computer screen, which was facing the hallway. Interview with Licensed Practical Nurse 1 on July 25, 2024, at 8:33 a.m. confirmed that she should have covered the residents' personal information when leaving the medication cart by securing the computer screen. Interview with the Director of Nursing on July 25, 2024, at 11:51 a.m. confirmed that the computer screen with Resident 137's personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and grievance records, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievance regarding dietary complaints for one of 48 residents reviewed (Resident 5). Findings include: The facility's policy regarding grievances, dated October 13, 2023, indicated that it is the policy of the facility to acknowledge any resident grievance and actively work toward a resolution. The grievance official and/or designee will meet with the party filling the grievance to discuss findings and necessary corrective action. A review of the facility's grievance logs for six months revealed no grievances related to food; however, minutes from the resident council meeting on April 29, 2024, revealed that Resident 5 had concerns with hot food. She documented that it would be nice to have the hot meal cart at all meals. The meals are hotter and taste better. A memo from the Director of Resident and Community Engagement, dated May…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, and investigation documents, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were free from abuse and neglect for one of 48 residents reviewed (Resident 63). Findings include: The facility's abuse policy, dated October 13, 2023, indicated that residents have the right to be free from any verbal, sexual, physical, and mental abuse; corporal punishment; involuntary seclusion; exploitation; and misappropriation of resident property. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff or other agencies serving the individual, family members or legal guardians, friends or other individuals. The intent of the policy is to develop and maintain a proactive process of detection and prevention of resident mistreatment, neglect, abuse, and misappropriation of property. Any staff member found guilty of abusing,…

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

Based on review of facility policies, clinical records, and facility investigation documents, as well as staff interviews, it was determined that the facility failed to prevent the misappropriation of medication for one of 48 residents reviewed (Resident 111). Findings include: The facility's policy regarding abuse, dated October 13, 2023, indicated that misappropriation included the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 111, dated May 28, 2024, revealed that the resident was cognitively intact, required extensive assistance for daily care needs, and had a diagnosis of chronic pain. Physician's orders for Resident 111, dated May 29, 2024, included an order for the resident to receive one 350 milligrams (mg) tablet of Carisoprodol (a muscle relaxant) four times a day. A facility investigation document, dated June 1, 2024, at 6:30 a.m. revealed that on…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the ombudsman in writing regarding the reason for transfers/discharge to hospital for five of 48 residents reviewed (Residents 11, 47, 67, 73, 108). Findings include: The facility's policy regarding Emergent Facility Initiated Discharge/Transfer reporting to the Ombudsman, dated October 13, 2023, indicated that the facility is to report emergent facility discharges/transfers to the State Long Term Care Ombudsman on a monthly basis. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated August 18, 2024, revealed that the resident was cognitively impaired, was clearly understood and able to understand others, required assistance with care needs, was receiving antipsychotic medications, and had diagnoses that included hyponatremia (low sodium in the blood). Nursing notes for Resident 11, dated September 3, 2024, at 10:27 a.m., revealed that the resident was agitated and…

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

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was created to reflect the resident's specific care needs for one of 48 residents reviewed (Resident 84). A facility policy dated, October 13, 2023, revealed that the purpose of the interim care plan on admission and comprehensive care plans were driven by the CAA process to address resident concerns and resident unique characteristics, strengths, weakness, preferences, and needs which require interdisciplinary intervention. It will include diagnosis, activity level, diet, medication, treatments, limitations, and specific requests for therapeutic interventions and will provide directions to nursing services with the goal of maintaining health status and addressing acute and chronic illness or discharge plan while providing a safe and therapeutic environment thereby eliminating the need for hospitalization A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for…

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

Based on review of policy and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possible by transporting a resident without leg rests for one of 48 residents reviewed (Resident 26). Findings include: The facility's policy for transportation, dated October 13, 2023, revealed that footrests must be used when staff, family, volunteers and healthcare partners are assisting residents who are transported by wheelchair, broad chair or any other chair with attachable footrests to prevent accident/injury. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 26, dated July 2, 2024, revealed that the resident was cognitively impaired, required maximum assistance for all of her care, and used a broda chair (a wheelchair with the ability to tilt and recline). Observations on July 22, 2024, at 2:30 p.m. revealed that Nursing Assistant 10 pushed Resident 26 in a broda chair from…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for monitoring output were followed for one of 48 residents reviewed (Resident 73) who had an indwelling urinary catheter. Findings include: The facility's policy regarding measuring output, dated October 13, 2023, indicated that output is to be monitored for residents that receive tube feedings, have a foley catheter, edema, dehydration, vomiting, IV fluids, specific diagnoses that require intake and output, and anyone that has a physician's order. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 73, dated May 8, 2024, revealed that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder). Physician's orders for Resident 73, dated February 9, 2024, included an order for staff to monitor…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that fluid restrictions were being followed for one of 48 residents reviewed (Resident 58) and failed to ensure that a resident's weight was obtained and documented as per physician's order for a resident with a documented history of weight loss for one of 48 residents reviewed (Resident 73). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58, dated June 14, 2024, indicated that the resident was cognitively intact, required assistance from staff for care, and had a diagnosis of kidney failure. A care plan for Resident 58, dated March 14, 2024, revealed that the resident was to be on a 1500 cc/day fluid restriction allowing 960 cc of fluid from dietary, 240 cc of fluid for day shift, 240 cc of fluid for evening shift, and 60 cc of fluid for night shift. A review of Resident 58's medical record revealed no documented evidence that the fluid restriction was being followed. Interview with…

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

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents who were receiving tube feedings received appropriate treatment and services to prevent complications for one of 48 residents reviewed (Resident 30). Findings include: The facility's policy regarding Enteral Feeding, dated October 13, 2023, indicated that prior to administering enteral feedings, the peg tube should be checked for placement. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 30, dated April 25, 2024, revealed that the resident was cognitively impaired, was usually understood and usually understood others, required assistance with care needs, and had a feeding tube (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications to a person who is unable to eat or drink by mouth). The current care plan for Resident 30 indicated that the resident had a need for a feeding tube and that it…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that dialysis residents had an active physician's order to attend dialysis, failed to obtain physician's orders for the care and monitoring of dialysis sites, and failed to provide communication with dialysis facility for one of 48 residents reviewed (Resident 58). Findings include: The facility's policy regarding care for residents who receive dialysis (mechanical process that cleanses the blood when the kidneys are not functioning properly), dated October 13, 2023, indicated that a physician's order would be obtained for dialysis to establish the days of the week that the dialysis will be given. Observation and a communication form that has been completed by the dialysis clinic will be scanned into the resident's electronic medical record. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58, dated July 14, 2021, indicated that the resident was cognitively intact, required assistance from staff for daily…

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 personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for two of five nurse aides reviewed (Nurse Aides 11 and 12). Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire, annual performance evaluations for Nurse Aides 11 and 12 were due between November 2023 and February 2024. As of July 24, 2024, there was no documented evidence that annual performance evaluations were completed as required for Nurse Aides 11 and 12. Interview with the Director of Nursing on July 24, 2024, at 2:35 p.m. confirmed that she could not provide evidence that annual performance evaluations were completed as required for Nurse Aides 11 and 12. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(a)(c) Staff Development.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide appropriate treatment and services for residents with dementia-related behaviors and failed to develop and implement an individual person-centered plan to address dementia-related behavioral symptoms displayed for one of 48 residents reviewed (Resident 3) who had dementia. Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated July 3, 2024, revealed that the resident was cognitively impaired; was clearly understood and able to understand others; required assistance with care needs; was receiving antidepressant, antianxiety and antipsychotic medications; and had diagnoses that included depression, anxiety, and dementia. The current care plan for behavior for Resident 3, dated October 30, 2023, revealed inappropriate behaviors related to dementia that included screaming, hitting at staff, and refusing care and medications. Interventions included to monitor behaviors and attempt to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart, failed to label medications with the date they were opened in one of eight medication carts reviewed (B100 Room), and failed to ensure the narcotic box was properly affixed in the refrigerator. Findings include: The facility's policy regarding the security of the medication cart, dated October 13, 2023, indicated that the nurse was to secure the medication cart during the medication pass to prevent unauthorized entry, and the medication cart was to be securely locked at all times when out of the nurse's view. Observations on July 25, 2024, at 8:23 a.m. revealed that a medication cart in the hallway was unlocked and unattended by Licensed Practical Nurse 1 when she went into Resident 137's room to provide care to resident. Interview with Licensed Practical Nurse 1 on July 25, 2024, at 8:27 a.m. confirmed that her medication…

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

Based on review of policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to provide dental services to meet the needs of each resident for one of 48 residents reviewed (Resident 8). Findings include: The facility's dental services policy, dated October 13, 2023, indicated that all residents are to be provided annual oral assessments by a licensed dentist/hygienist. A dental progress note for Resident 8, dated May 25, 2023, indicated that the resident was not seen by 360 dental due to her refusal for treatment. There was no documented evidence in the resident's clinical record to indicate a follow-up appointment was attempted. A nursing note for Resident 8, dated December 28, 2023, at 6:00 p.m., indicated that the resident was complaining of right-side facial pain. The resident was crying in pain when she asked for Tylenol. She stated the pain was from her ear to her mouth. A nursing note for Resident 8, dated January 26, 2024, at 1:34 p.m. indicated that the resident had no pain in the past five days and had upper and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility records and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at palatable temperatures. Findings include: Facility grievance logs revealed no grievances related to food; however, resident council meeting minutes on April 29, 2024, revealed that Resident 5 had concerns with hot food. She documented that it would be nice to have the hot meal cart at all meals. The meals are hotter and taste better. A memo from the Director of Resident and Community Engagement, dated May 2, 2024, revealed that she had spoken with the Dietary Director regarding food concerns, including temperatures of food. She stated she would have dietary check to make sure the temperatures are properly done and food is served at correct temperatures. A memo with attached education from the Dietary Director, dated May 4, 2024, revealed that she had spoken to dietary staff to make sure temperatures are taken for each meal. She had attached a list of employees…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two of 48 residents reviewed who were receiving hospice services (Residents 36, 45). Findings include: An agreement between the facility and the hospice provider (end-of-life services) indicated that the hospice provider would maintain medical records for each hospice patient. Such records will be prepared and maintained with federal and state law, rules, regulations, procedures, policies, guidelines, and generally accepted medical record practices. A record of all services provided to the patient and events regarding the patient's care will be located at the facility. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated June 11, 2024, indicated that the resident was cognitively impaired, required extensive assistance with daily care needs including transfers, was receiving…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficient practices. Findings include: The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending, September 14, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending July 25, 2024, identified repeated deficiencies related to unresolved grievances, the accuracy of Minimum Data Set (MDS) assessments (federally-mandated assessments of residents' abilities and care needs), initiating residents' care plans, revising residents' care plans, quality of care, accident hazards, maintaining proper nutrition and…

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

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 48 residents reviewed (Resident 5). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicates that multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its…

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 employee education records, as well as staff interviews, it was determined that the facility failed to ensure that nurse aides completed the required annual education for two of five nurse aides reviewed (Nurse Aides 12, 18) Findings include: A facility policy regarding Orientation/Training/Evaluation, dated October 13, 2023, indicated that a minimum of 12 hours of in-service education will be provided to nurse aides annually based on their anniversary hire date (day and month). Review of the employee education file for Nurse Aides 12 and 18 revealed that there was no documented evidence to indicate that a minimum of 12 hours of in-service education was completed annually based on their anniversary hire date (day and month). Interview with the Director of Nursing on July 24, 2024, at 2:35 p.m. confirmed that there was no documented evidence to indicate that Nurse Aides 12 and 18 completed a minimum of 12 hours of in-service education based on their anniversary hire date (day and month) as required. 28 Pa. Code 201.18(b)(3)(e)(1) Management. 28 Pa. Code 201.19…

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

Based on review of policies, as well as interviews with residents and staff, it was determined that the facility failed to ensure that residents and/or their representatives could file a grievance/concern anonymously by failing to ensure that information on how to file a grievance or complaint was available to residents or their representatives without asking. Findings include: The facility's Grievance Process policy, dated October 11, 2022, indicated that anyone may file a grievance anonymously if they chose to do so. During an interview with a group of residents on September 12, 2023, at 2:00 p.m. the residents indicated that they would like to be able to file a grievance or make a statement about something that interests them on a grievance form and that they would like to remain anonymous in doing so; however, they are not aware of any way to file a grievance without giving it to staff. Interview with the Nursing Home Assistant Administrator on September 14, 2023, at 3:49 p.m. revealed that the facility's grievance forms were located behind each nursing station, and that nurses…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans for individualized resident care needs for four of 49 residents reviewed (Residents 44, 45, 69, 70). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 44, dated August 12, 2023, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had a Stage 2 pressure ulcer (partial thickness wound). A physician's order for Resident 44, dated September 13, 2023, included an order for the resident to have medi-honey paste applied to her right upper buttock and covered with gauze once daily. There was no documented evidence that Resident 44's care plan, most recently revised August 12, 2023, included specific and individualized interventions related to her Stage 2 pressure ulcer. An interview with the Assistant Director of Nursing on September 14, 2023, at 3:20 p.m. revealed that there was no care plan 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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to revise/update care plans for seven of 49 residents reviewed (Residents 10, 36, 47, 48, 49, 62, 69). Findings include: The facility's policy regarding care plans, dated October 11, 2023, indicated that nurses and interdisciplinary team members were responsible for updating the resident's care plan to reflect changes in the resident's status. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated July 31, 2023, indicated that the resident was cognitively impaired and required assistance from staff for her daily care needs. Resident 10's care plan, dated June 30, 2023, indicated that the resident was medicated with Lovenox (an anti-coagulant); however, the medication had been discontinued. Interview with the Director of Nursing on September 12, 2023, at 2:41 p.m. confirmed that Resident 10's care plan should have been updated to reflect the Lovenox having been…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with proper colostomy care for one of six residents reviewed (Resident 19). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated August 18, 2023, revealed that the resident was moderately cognitively impaired, required limited to extensive assistance from staff with daily care needs, and had a colostomy (a hole (stoma) in the abdominal wall which allows waste to leave the body). Physician orders, dated May 23, 2023, included an order for the stoma area and peristomal area (area around stoma) be cleansed with warm water, dried thoroughly, and a new appliance applied. The order did not include how frequently the appliance was to be changed. A care plan, dated May 24, 2023, indicated that the resident had a colostomy and the ostomy bag was to be changed when it was loose or leaking, and staff were to change the flange (secures…

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

Based on review of policies, clinical record reviews, and staff interviews, it was determined that the facility failed to monitor a resident's weight as ordered by the physician for one of 49 residents reviewed (Resident 111). Findings include: The facility's policy regarding weighing residents, dated October 10, 2022, indicated that the purpose was to determine weight gain or loss, as changes in weight are frequent indicators of the resident's condition. A quarterly admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 111, dated May 5, 2023, revealed that the resident was severly cognitively impaired, had diagnoses that included Alzheimer's and dementia, and required staff to set up her meals. Current care plans indicated that the resident was at potential risk for altered nutritional status related to her dementia diagnosis. Physician's orders for Resident 111, dated January 6, 2023, revealed that the resident was to be weighed weekly. Resident 111's weight records revealed that her weight was taken on January 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.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed, resulting in a significant medication errors for two of 49 residents reviewed (Residents 51, 72). Findings include: The facility's policy regarding Medication Administration, dated October 11, 2022, indicated that prescribed medications were to be safely administered in accordance with the physician order and manufacturer's specification. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated July 27, 2023, revealed that the resident was cognitively intact, required staff assistance for daily care tasks, and medicated with an anticoagulant (blood thinner). The resident's care plan, most recently updated on July 27, 2023, revealed that the resident medicated with an anticoagulant and was to be medicated per physician's orders. Physician's orders for Resident 51, dated July 31, 2023, included an order for the resident to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food service safety, by failing to ensure that dietary staff wore hair coverings that completely covered their hair. Findings include: The facility's policy regarding hair restraints for dietary employees, dated October 11, 2022, revealed that hair nets were to be worn at all times, and that all the hair should be placed under the hairnet. Observations in the [NAME] Courtyard dining area on September 11, 2023, at 12:34 p.m. revealed that Dietary Aide 7 was plating food items, which included pulled pork and sweet potatoes fries, with a hairnet on that did not fully cover her hair. Approximately three to four inches of hair tendrils fell down on both sides of her head onto her collar. Observations in the [NAME] Courtyard dining area on September 13, 2023, at 8:53 a.m. revealed that Dietary Aide 8 was plating food, which included pancakes,…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for one of 49 residents reviewed (Resident 97). Findings include: The facility policy for medication administration subcutaneous insulin, dated October 11, 2022, indicated that after the insulin is administered staff are to document the injection on the Medication Administration Record (MAR) along with the site. The diagnosis record for Resident 97, dated July 25, 2023, included chronic kidney disease and diabetes (disease that results with too much sugar in the blood). Physician's orders for Resident 97, dated August 9, 2023, included an order for Novolog insulin (fast acting insulin) to be provided four times a day based on the sliding scale coverage order. For a blood sugar of 201-250 mg/dL give 2 units of Novolog insulin; for a blood sugar of 251-300 mg/dL give 4 units of Novolog insulin; for a blood sugar of 351-400 mg/dL give 8 units of Novolog insulin; for a blood sugar of 401-450 mg/dL give 10…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and to ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending August 11, 2022, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending September 14, 2023, identified repeated deficiencies related to accurate Minimum Data Set Assessments, quality of care, safety/accidents, nutrition/hydration status, and complete and accurate medical records. The facility's plan of correction for a deficiency regarding a failure to maintain accurate Minimum Data Set Assessments, cited during 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 of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 49 residents reviewed (Residents 22, 101, 103). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that if the resident had a fall since admission, entry or re-entry, or a prior assessment, then Section J1800 was to be coded (1) Yes, and Section J1900 was to be completed. If the resident had a fall with no injury since admission, entry or re-entry, or a prior assessment then J1900A was to be coded with the number of falls. If the resident had a fall with an injury (skin tears, abrasions, lacerations, superficial bruises, hematoma) since admission, entry or re-entry, or a prior assessment then Section J1900B was to be coded with the number of falls. If the resident had 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 policies, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 49 residents reviewed (Resident 36). Findings include: The facility's policy on following physican's orders, dated October 11, 2022, revealed that the purpose is to accurately and completely act in accordance with physican orders. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated August 2, 2023, indicated that the resident was cognitively impaired; required total assistance for bed mobility, transfers, and dressing; had diagnoses that included, stroke, heart disease and joint contratures; and had a current care plan that included interventions to monitor for edema. Physician's orders for Resident 36, dated August 23, 2019, included an order for the resident to wear bilateral TED hose (stockings to prevent blood clots) on in the morning (a.m.) and off in evening (p.m). Observations of Resident 36 on September 11, 2023, at 12:05 p.m. and…

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

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that preventative pressure ulcer interventions were applied as recommended and care planned for one of 49 residents reviewed (Resident 36). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a residents abilities and care needs) for Resident 36, dated October 11, 2022, revealed that the resident required extensive assistance for daily care tasks and was at risk for pressure ulcers (skin breakdown caused by prolonged, unrelieved pressure) due to limited mobility and contractures. Occupational Therapy care notes, dated September 29, 2022, indicated that Resident 36 would benefit from a positioning device in the left hand. Restorative care notes, dated October 19, 2022, indicated that Resident 36 has pain issues and could only tolerate gentle joint mobilization. Therefore, it was recommended that a rolled wash cloth be placed in the left hand at all times, only to be removed for hygiene purposes. Current care plans indicated…

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, as well as staff interviews, it was determined that the facility failed to ensure that a resident's plan of care was followed for fall prevention and transfers for one of 49 residents reviewed (Resident 29). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated August 9, 2023, revealed that the resident was cognitively impaired, required extensive assist with daily care needs including transfers, and had diagnosis that included dementia. A fall care plan, dated July 6, 2023, revealed that the resident was to be transferred as a two-person assist or stand-up lift as needed. Nursing note for Resident 29, dated August 1, 2023, at 5:51 a.m. revealed that the resident was transferring off the toilet with a nurse aide when she lost her balance. The nurse aide then lowered the resident to the floor. Interview with the Assistant Director of Nursing on September 14, 2023, at 1:45 p.m. confirmed that Resident 29 was transferred with one assist and not 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 reviews, observations, and staff interviews, it was determined that the facility failed to ensure oxygen tubing and concentrator filters were changed as ordered by the physician for two of 49 residents (Residents 69, 91). Findings include: A quarterly MDS assessment for Resident 69, dated August 11, 2023, indicated that the resident was cognitively impaired, required assistance from staff for his daily care needs, and that he used oxygen. Physician's orders for Resident 69, dated August 6, 2022, included an order for the resident's air filter on the oxygen concentrator to be cleaned every Saturday night and to change the oxygen tubing at that time. Observations of Resident 69's oxygen tubing on September 11, 2023, at 1:35 p.m. and again on September 14, 2023, at 10:05 a.m. revealed that his oxygen tubing was dated September 2, 2023 and should have been changed September 9, 2023. Interview with Licensed Practical Nurse 5 on September 14, 2023, at 10:55 a.m. revealed that Resident 69's oxygen tubing should have been changed on September 9 and it was not. A…

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

Based on review of hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that they obtained the required information from the contracted hospice provider for two of 49 residents reviewed (Residents 79,103). Findings include: An agreement between the facility and a hospice provider (provider of end-of-life services), dated December 3, 2015, indicated that the hospice provider would provide information to the facility to facilitate coordination of care that included the most recent hospice plan of care specific to each patient, physician certification or recertification, and a hospice benefit of elections form (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness). A facility policy, dated October 11, 2022, indicated that documentation of Election Form, Physician Certification, and the care plan are on the medical record and scanned into the Electronic Medical Record under the hospice tab. The current list of diagnoses 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.