Twin Lakes Rehabilitation And Healthcare Center

Based on observations and resident and staff interviews, it was determined that the facility failed to serve food that was palatable to residents.Findings include:Interview with Resident 1 on November 17, 2025, at 1:33 p.m. revealed that he did not like the food because the meat and potatoes were always over cooked and tough to chew.Interview with Resident 94 on November 17, 2025, at 1:19 p.m. revealed that the meat was very tough, and at times she could not eat what was served. She said that the meat was usually dry and too tough to cut or chew. Observations in the kitchen on November 20, 2025, at 12:23 p.m. revealed that the lunch meal consisted of Salisbury steak, scalloped potatoes, mixed vegetables, and gelatin. These items were placed on a test tray at 12:30 p.m. and tasted for palatability. The Salisbury steak was covered with gravy, hard and crispy around the edges and tough to cut. Interview with the Dietary Manager on November 20, 2025, at 12:33 p.m. confirmed that the Salisbury steak was harder and crispy on the edges. She indicated that the oven does not heat evenly, 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 policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions. Findings include:The facility's policy related to sanitation, dated July 28, 2025, revealed that all equipment, food contact surfaces and utensils would be washed to remove or completely loosen soils by using manual or mechanical means necessary, and sanitized using hot water and/or chemical sanitizing solutions. Manual washing and sanitizing would employ a three-step process for washing, rinsing and sanitizing: scrape food particles and wash using hot water and detergent; rinse with hot water to remove soap residue; and sanitize with hot water or chemical sanitizing solution.Observations in the kitchen on November 17, 2025, at 9:08 a.m. revealed that the three-compartment sink was being used and there were utensils and pans drying on the counter; however, the sanitizer log, dated November 2025, revealed that there was no documented evidence that temperature/chemical checks were being done for each…

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

Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bell was within reach for one of 46 residents reviewed (Resident 85).Findings include: Review of the facility's call bell policy, dated July 28, 2025, indicated that the call light was to be accessible to the resident when in bed.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 85, dated October 31, 2025, revealed that the resident could make herself understood and understand others, required assistance from staff for care needs, was incontinent of bowel and bladder, and had diagnoses that included seizures and stroke. A care plan for Resident 85, dated October 26, 2025, indicated that the resident was at risk for falls due to impaired mobility, and the call bell was to be in reach.Observations of Resident 85 on November 17, 2025, at 11:10 a.m. revealed that the resident was laying on her bed requesting pain medication. Her call bell was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for five of 48 residents reviewed (Residents 46, 68, 71, 83, 122). Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that an admission MDS assessment was to be completed no later than 14 days (admission date + 13 calendar days) following admission.An admission MDS assessment for Resident 46 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on October 28, 2025, which was 14 days after admission.An admission MDS 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.

Based on clinical record reviews, as well as resident and staff interviews, it was determined that the facility failed to implement an individualized care plan for dental needs for one of 46 residents reviewed (Resident 89). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 89, dated September 16, 2025, indicated that the resident was alert and oriented, and required assistance for daily care, including oral care.A physician's order for Resident 89, dated November 2025, revealed that the resident was scheduled for dental extractions in January 2026 and that she required pre-testing for extractions in December 2025.There was no documented evidence that a care plan was developed to address Resident 89's care needs related to her dental problems.An interview with Resident 89 on November 17, 2025, at 11:38 a.m. revealed that the resident had multiple teeth missing, had obvious dental carries, as well as misaligned front teeth. She indicated that she was in need of dental care to pull several…

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 resident and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for one of 46 residents reviewed (Resident 7). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated October 31, 2025, revealed that the resident was cognitively impaired, was dependent on staff for daily care needs and had diagnoses that included anxiety, dementia and psychosis (a mental state involving a loss with reality with symptoms of delusions and hallucinations). Physician's orders, dated April 25, 2025, included an order to discontinue Resident 7's quetiapine (an antipsychotic medication). A care plan for Resident 7, dated June 12, 2025, indicated that the resident was at risk for adverse effects related to the use of antipsychotic medication. Interview with the Director of Nursing on November 19, 2025, at 1:25 p.m. confirmed that Resident 7's care plan should have 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 observations and staff interviews, it was determined that the facility failed to ensure that foot care needs were provided timely for one of 46 residents reviewed (Resident 6). Findings include: The facility's policy regarding podiatry services (specialized foot care), dated July 28, 2025, indicated that the residents were to receive the appropriate care and treatment in order to maintain mobility and foot health. Overall foot care included the care and treatment of medical conditions to prevent foot complications from these conditions (e.g., diabetes, peripheral vascular disease, immobility, etc.). An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated September 18, 2025, indicated that the resident was alert and oriented, dependent on staff for daily care needs, and had a diagnosis of diabetes (disease that interferes with blood sugar control). A podiatry note, dated May 16, 2025, revealed that Resident 6 was seen for routine podiatry care 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 review of policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from accidents that resulted in injury for one of 46 residents reviewed (Resident 46). This deficiency is being cited as past non-compliance.Findings include:The facility's Assistive Devices and Equipment policy, dated July 28, 2025, indicated that residents who did not self-propel, should have leg rests on their wheelchair when being transported. admission paperwork for Resident 46, dated October 14, 2025, revealed that the resident was admitted to the facility on [DATE], from the hospital with a diagnosis of Covid pneumonia, stasis dermatitis of bilateral lower extremities, and also had a history of trans ischemic attack (mini-stroke). Resident on two liters of oxygen via nasal cannula. She was alert and oriented and required assistance from two staff members for care. Resident 46 utilized a walker or a…

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

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 46 residents reviewed (Resident 67). Findings include:The facility's policy regarding controlled substance disposal, dated July 28, 2025, indicated that when a fentanyl patch was removed from a resident, the patch was to be folded in half with the adhesive attaching to the adhesive, and the patch was placed in inert material, such as cat litter, to render the mixture unusable in the presence of two licensed personnel. The disposal was to be documented per the facility policy.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 67, dated September 30, 2025, revealed that the resident was cognitively intact, was scheduled routine pain medications, had complaints of difficulty or pain when swallowing, had a feeding tube (a mechanical device surgically implanted 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide medications as ordered by the physician, resulting in a significant medication error for one of 46 residents reviewed (Resident 115). Findings include:The facility policy for medication administration, dated July 28, 2025, indicated that medications were to be administered per physician's orders. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 115, dated October 27, 2025, indicated that the resident was cognitively intact, had diagnoses that included atrial fibrillation (irregular heartbeat), and received anticoagulant (blood thinner) medications. A care plan for Resident 115, dated October 27, 2025, revealed that the resident was to be medicated with an anticoagulant per the physician's orders.Physician's orders for Resident 115, dated November 13, 2025, included orders for the resident to receive 5 milligrams (mg) of Coumadin (blood thinner) every day.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 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 plan of corrections for an annual survey ending October 9, 2024, and a complaint survey ending May 14, 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 November 20, 2025, identified repeated deficiencies related to a failure to accommodate the needs of a resident, failure to develop individualized care plans, failure to revise care plans, and failure to clarify questionable physician's orders.The facility's plan of correction for a deficiency regarding accommodations of need, 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 facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for one of eight residents reviewed (Resident 6). Findings include: The facility policy for medication administration, dated January 15, 2025, indicated that medications are administered in accordance with prescriber orders, and that the following information is checked/verified for each resident prior to administering medications: allergies to medications; and vital signs, if necessary. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated February 28, 2025, revealed that the resident was cognitively intact, independent with personal care needs, and had diagnoses that included diabetes. Physician's orders for Resident 6, dated February 28, 2025, included an order for the resident to receive one-half tablet of 25 milligrams (mg) of Metoprolol Tartrate (used to treat high blood pressure) twice a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of four residents reviewed (Resident 1). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 10, 2025, revealed that the resident was understood, could understand others, had diagnosis that included hemiplegia (paralysis on one side of the body), chronic obstructive pulmonary disease (COPD - a condition caused by damage to the airways or other parts of the lung), and respiratory failure (a serious condition where the respiratory system is unable to adequately supply the body with oxygen or remove carbon dioxide), received oxygen therapy, suctioning and tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) care. A care plan…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify to update the admitting facility with information about laboratory testing and results for one of three residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 27, 2024, indicated that the resident was cognitively intact, usually understood and could sometimes understand, required assistance from staff for his daily care needs, was always incontinent of bowel and bladder, and had diagnoses that included debilitating cardiorespiratory conditions. Physician orders for Resident 2, dated September 4, 2024, included an order for Clostridioides difficile (C-diff - infectious bacteria that causes diarrhea, an inflammation of the colon, and can be life-threatening) toxin stool for frequent watery stools. A nursing note for Resident 2, dated September 4, 2024, at 5:20 p.m., indicated that the resident had recurrent watery stools…

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 obtain laboratory studies as ordered by the physician for one of three residents reviewed (Resident 2). Findings include: A facility policy regarding test results, dated July 26, 2024, indicated that results of laboratory, radiological, and diagnostic testing shall be reported in writing to the resident's attending physician or to the facility. The Director of Nursing services or charge nurse receiving the test results, shall be responsible for notifying the physician of such test results. The signed and dated reports of all diagnostic testing shall be made part of the clinical record. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 27, 2024, indicated that the resident was cognitively intact, usually understood and could sometimes understand, required assistance from staff for his daily care needs, was always incontinent of bowel and bladder, and had diagnoses that…

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

Based on clinical record reviews, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were provided with showers/baths as scheduled for two of 61 residents reviewed (Residents 36, 68). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated August 22, 2024, revealed that the resident was cognitively intact, was dependent on staff for bathing/showering, and had diagnoses that included rheumatoid arthritis (chronic disease that causes inflammation around the body and commonly presents with pain in the joints). Resident 36's bathing record for August and September 2024 revealed that the resident was to receive a shower every Monday during the evening shift and every Friday during the day shift; however, documentation during that time revealed that the resident was provided a bed bath on Mondays and Thursdays on day shift, with the exception of a shower provided on August 19, 2024; September 19, 2024; and September 30, 2024. No showers…

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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide appropriate care to ensure that interventions were in place to prevent urinary tract infections for three of 61 residents reviewed (Residents 13, 80, 104) who had indwelling urinary catheters. Findings include: The facility policy for urinary catheter care, dated July 19, 2024, indicated that the catheter tubing and drainage bag were to be kept off the floor, and staff were to document the date and time that catheter care was given. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated August 23, 2024, indicated that the resident was cognitively intact, required assistance from staff for care needs, had an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), and had a diagnosis that included neurogenic dysfunction of the bladder (bladder lacks control due to nerve or muscle problems). Nurse aide documentation for…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for two of 61 residents reviewed (Residents 88, 109) who had a feeding tube. Findings include: The facility policy regarding enteral tube feedings, dated July 19, 2024, indicated that prior to the administration of the tube feeding, staff were to verify the placement of the feeding tube and were to document the verification of the tube placement. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 88, dated August 19, 2024, indicated that the resident was cognitively impaired, required assistance from staff for daily care tasks, and had a feeding tube. A care plan, dated January 15, 2024, revealed that staff were to check feeding tube placement and residuals per the guidelines or physician's order. Physician's orders for Resident 88, dated August 16, 2024, included orders for the resident to receive Jevity 1.5 cal (a tube feeding…

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 long-term intravenous catheters were flushed per facility policy for three of 61 residents reviewed (Residents 101, 104, 136). Findings include: The facility's policy regarding the flushing of peripheral and midline intravenous catheters (a catheter that is placed in a peripheral vein for long-term administration of fluids and/or medication), dated July 19, 2024, indicated that the peripheral or midline catheter was to be flushed with 10 cubic centimeters (cc's) of normal saline (sterile salt and water solution) before and after each use. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 101, dated September 22, 2024, indicated that the resident was cognitively intact, was understood and able to understand others, required assistance with care needs, received an intravenous medication, and had an infection to his left shoulder. Physician's orders for Resident 101,…

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 physician visits were conducted at least every 60 days after the first 90 days of admission for three of 61 residents reviewed (Residents 8, 13, 61). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated September 17, 2024, revealed that the resident was cognitively impaired, was understood and able to understand others, required assistance with care needs, and had diagnoses that included dementia with behaviors and chronic obstructive pulmonary disease (COPD) (chronic lung disease making breathing difficult). A physician's note, dated February 5, 2024, indicated that Resident 8 disenrolled from Senior Life Services and transferred physicians effective February 1, 2024. Clinical record reviews for Resident 8 revealed that the resident was seen by the physician on February 26, 2024, and July 29, 2024. There is no documented evidence that Resident 8 was seen by 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 and resident and staff interviews, it was determined that the facility failed to honor the resident's right to make informed choices and participate in his/her treatment for one of 61 residents reviewed (Resident 84). Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 84, dated August 21, 2024, indicated that the resident could be understood and could understand others, and was alert and oriented. A nursing note for Resident 84, dated May 24, 2024, revealed that the resident requested to have lab work drawn. According to Resident 84's clinical record, she had labs drawn and resulted on May 28, 2024. There was no documented evidence in Resident 84's clinical record that anyone reviewed her lab results with her. Interview with Resident 84 on October 6, 2024, at 10:58 a.m. revealed that she requested lab work be done; however, no one reviewed the results with her. Interview with the Director of Nursing on October 8, 2024, at 2:00 p.m. revealed that she stated…

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 resident and staff interviews, it was determined that the facility failed to determine if residents were safe to self-administer medications for three of 61 residents reviewed (Residents 19, 78, 108). Findings include: The facility's medication administration policy, dated July 19. 2024, indicated that medications are administered in a safe manner, and as prescribed. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. The facility's self-administration policy, dated July 19, 2024, indicated that residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. A quarterly Minimum Data Set (MDS)…

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 resident and staff interviews, it was determined that the facility failed to ensure that call bells were within reach for one of 61 residents reviewed (Resident 59). Findings include: A review of the facility Answering the Call Light policy, dated July 19, 2024, indicated that the facility was to ensure that the call light was accessible to the resident when in bed. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 59, dated July 31, 2024, revealed that the resident was understood and able to understand others, required assistance from staff for care needs, and had diagnoses that included glaucoma (chronic eye disease that damages the optic nerve and causes vision loss) and hemiplegia/hemiparesis (paralysis or weakness to one side of the body due to brain injury) following a cerebral vascular accident (an event caused by poor blood flow or bleeding to in the areas of the brain). A fall risk care plan for Resident 59, dated October 2,…

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 (instructions regarding the provision of health care when the resident is incapacitated) or assist in formulating an advance directive for four of 61 residents reviewed (Residents 14, 17, 59, 101). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated August 16, 2024, indicated that the resident was clearly understood and clearly able to understand others, required assistance with care needs, and had a diagnosis of dementia. An annual MDS assessment for Resident 17, dated September 7, 2024, revealed that the resident was cognitively intact, was clearly understood and clearly able to understand others, required assistance for care needs, and had diagnoses that included schizophrenia (a serious mental disorder that affects how people interpret reality), anxiety, depression,…

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 personnel files, as well as staff interviews, it was determined that the facility failed to complete a criminal background check prior to hire for one of three nurse aides reviewed (Nurse Aide 3). Findings include: The facility's policy regarding abuse, neglect, exploitation, and misappropriation prevention, dated July 19, 2024, indicated that the facility will conduct employee background checks and will not knowingly employ any individual who has been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Review of the personnel file for Nurse Aide 3 revealed that he was hired on June 6, 2024, but as of October 8, 2024, there was no evidence that a criminal background check was completed. Interview with the Human Resource Director on October 8, 2024, at 2:30 p.m. confirmed that there was no documented evidence that a criminal background check was completed for Nurse Aide 3 prior to his date of hire. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative in writing of the transfer and reason for hospitalization for four of 61 residents reviewed (Residents 13, 88, 109, 131). This deficiency was cited as past noncompliance. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated August 23, 2024, indicated that the resident was cognitively intact, required assistance from staff for care needs, had an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), received dialysis (treatment to remove extra fluid and waste from the blood when the kidneys are not able to), and had diagnoses that included neurogenic dysfunction of the bladder (bladder lacks control due to nerve or muscle problems) and End-Stage Renal Disease (kidneys no longer work as they should to meet the body's needs requiring dialysis or kidney transplant). A nursing note, dated August…

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 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 seven of 61 residents reviewed (Residents 6, 13, 51, 78, 80, 88, 128). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that Section N0415 (high risk drug classes) E (anticoagulant) was to be coded (1) is taking, if an anticoagulant (blood thinner) medication was administered while a resident at the facility during the seven-day assessment period. Physician's orders for Resident 6, dated April 17, 2024, included for the resident to receive 75 milligrams (mg) of Pradaxa (an anticoagulant) two times a day. Review of the Medication Administration Record (MAR) for…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans to address individualized resident care needs for two of 61 residents reviewed (Residents 70, 80). Findings include: The facility's policy regarding care plans, dated July 19, 2024, revealed that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented on each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions changes. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 70, dated August 5, 2024, revealed that the resident was cognitively intact and was receiving an anti-coagulant (blood thinner). Physician's orders for Resident 70, dated March 8, 2024, included an order for the resident to receive 10 milligrams (mg) of Xarelto (blood thinner)…

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 a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 61 residents reviewed (Residents 51, 80). Findings include: The facility's policy regarding care plans, dated July 19, 2024, revealed that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented on each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated September 24, 2024, indicated that the resident was cognitively intact, was understood and able to understand others, and required assistance with care needs. A physician's note for Resident 51, dated August 15, 2024, at 11:29 p.m.,…

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

Based on policy review, observations, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards regarding medication administration for two of 61 residents reviewed (Residents 47, 77). Findings include: Review of the facility policy for medication administration, dated July 19, 2024, revealed that medications are administered in a safe and timely manner and as prescribed. The Director of Nursing supervises and directs all personnel who administer medications and/or have relate functions. The individual administering the medication initials the residents Medication Administration Record on the appropriate line after giving each medication and before administering the next ones. Observations during medication administration on October 7, 2024, at 7:34 a.m. revealed that Licensed Practical Nurse 2 prepared medications for Resident 47 then picked up the medicine cup with the medications that she had just prepared, and another medicine cup with pills in that was prepared prior to the surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders regarding treatment administration were followed for one of 61 residents reviewed (Resident 80). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 80, dated September 8, 2024, indicated that the resident had moderate cognitive impairment, was dependent on staff for personal hygiene care, had diagnoses that included urinary tract infection and diabetes, and had one Stage 4 pressure ulcer (wound that occurs from prolonged pressure on the skin that that involves full thickness tissue loss with exposed bone, tendon, or muscle). Physician's orders for Resident 80, dated September 19, 2024, included orders to remove the resident's dressing, re-evaluate the wound, and contact the provider to obtain new orders for wound care any time the resident's negative wound pressure therapy (NWPT- treatment that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, as well as resident, family, and staff interviews, it was determined that the facility failed to ensure that residents had proper assistive devices to maintain adequate hearing for one of 61 residents reviewed (Resident 14). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated [DATE], indicated that the resident was understood and able to understand others and required assistance with daily care needs. Resident 14's care plan, dated [DATE], revealed that she had difficulty communicating and used hearing aids. A social services note, dated [DATE], at 11:56 a.m., indicated that Resident 14's right hearing aid was smashed and audiology took both hearing aids in an attempt to fix/replace them. An audiology consult note, dated [DATE], indicated that the right hearing aid was smashed and both hearing aids were taken for repair. Interview with Resident 14 on [DATE], during the initial…

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

Based on review of facility policies and clinical records, as well as staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder for one of 61 residents reviewed (Resident 113). Findings include: The facility's policy regarding trauma informed care, dated July 19, 2024, indicated that the facility would perform universal screenings of residents, which included a brief, non-specialized identification of possible exposures to traumatic events. The assessment involved an indepth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 113, dated September 20, 2024, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included anxiety, depression, Post…

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 personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for two of three nurse aides reviewed (Nurse Aides 8, 9). Findings include: The facility's policy regarding performance evaluations, dated July 19, 2024, indicated that performance evaluations were to be completed annually and thereafter. A list of nurse aides provided by the facility revealed that based on their months and days of hire, annual performance evaluations were due between April 8 and July 1, 2024, for Nurse Aide 8 and Nurse Aide 9. However, there was no documented evidence that annual performance evaluations were completed as required for these nurse aides. Interview with the Director of Nursing on October 8, 2024, at 2:30 p.m. confirmed that the annual performance evaluations were not completed as required for Nurse Aides 8 and 9. 28 Pa. Code 201.18(e)(1) Management.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician responded timely to pharmacy recommendations for one of 61 residents reviewed (Resident 61). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated September 19, 2024, revealed that the resident was cognitively intact, was understood and able to understand others, required minimal assistance with care needs, was taking an antipsychotic medication (medications used to treat mental health disorders), and had diagnoses that included dementia, Wernicke's encephalopathy (a degenerative brain disorder caused by a lack of vitamin B1), bipolar disorder (mood disorder), and depression. Physician's orders for Resident 61, dated October 6, 2023, included an order for the resident to receive 0.5 mg of Risperidone (antipsychotic medication) twice daily for bipolar disorder. Physician's orders for Resident 61, dated October 5, 2023, included an order for the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to provide a separately-locked, permanently-affixed compartment in the refrigerator for the storage of controlled drugs in one of two medication rooms reviewed (medication room on [NAME] unit), failed to discard an expired multi-dose inhaler in one of three carts reviewed ([NAME] long hall cart), failed to label an opened, multi-dose insulin vial in one of three carts reviewed ([NAME] long hall cart), and failed to ensure that medications were properly stored and labeled for two of 61 residents reviewed (Residents 78, 108). Findings include: The facility's policy regarding medication labeling and storage, dated [DATE], indicated that controlled substances (medications with the potential to be abused) and other drugs subject to abuse are separately locked in permanently-affixed compartments. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within…

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 provide adaptive eating equipment as ordered by the physician for one of 61 residents reviewed (Resident 42). Findings include: The facility's policy for assistance with meals, dated July 19, 2024, indicated that adaptive devices (special eating equipment and utensils) would be provided for residents who needed or requested them. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated July 21, 2024, indicated that the resident was cognitively intact and required set-up assistance from staff with eating. A therapy screen, dated June 20, 2024, revealed that the resident requested adaptive silverware due to arthritis in his hands. He complained of cramping in his hands after completing wheelchair mobility that affected his ability to hold standard utensils. He demonstrated independence with the use of built-up utensils (utensils with foam handles) and was…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 61 residents reviewed (Resident 130). Findings Include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 130, dated August 6, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included chronic obstructive pulmonary disease (COPD - a common lung disease that makes it difficult to breathe) and gastroesophageal reflux disease (GERD - a chronic condition that occurs when stomach contents leak into the esophagus, causing irritation and other symptoms). A care plan for the resident, dated May 20, 2024, revealed that the resident had an actual/potential for weight loss/gain and staff was to provide diet/supplements per orders. Physician's orders for Resident 130, dated May 14, 2024, included an order for the resident to receive regular texture, thin consistency, regular diet.…

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 a State Survey and Certification (Department of Health) survey ending November 9, 2023, and complaint investigation surveys ending March 5, 2024, and May 30, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending October 9, 2024, identified repeated deficiencies related to accuracy of Minimum Data Sets (MDS), creating and implementing care plans, revision of care plans, quality of care, and tube feeding management. The facility's plan of correction for a deficiency regarding 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 manufacturer's directions for use and observations, as well as staff interviews, it was determined that the facility failed to maintain two of three laundry dryers in safe operating condition. Findings include: Manufacturer's directions for use for the tumble dryer, dated February 2022, indicated to keep the area around the exhaust opening and adjacent surrounding area free from the accumulation of lint, dust, and dirt. The interior of the tumble dryer and exhaust duct should be cleaned periodically by qualified service personnel. Observations in the laundry department on October 8, 2024, at 8:44 a.m. revealed that in the compartment above the dryer drum where the gas line entered the back of the dryer towards the room with the washers and the middle dryer had an accumulation of lint. Interview with the Director of Environmental Services at the time of observation confirmed that there was an accumulation of lint. Interview with the Director of Maintenance on October 8, 2024, at 9:00 a.m. confirmed that there was an accumulation of lint in the compartment above the dryer…

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 provide a clean, homelike environment for one of 15 residents reviewed (Resident 10). Findings include: The facility's policy titled Homelike Environment, dated July 26, 2024, revealed that the objective was to provide a safe, clean, comfortable and homelike environment for residents. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated September 1, 2024, revealed that the resident was cognitively intact, required assistance with most daily care needs, and had diagnoses that included COPD (congestive obstructive pulmonary disease), quadriplegia, and drug abuse. Observations on September 11, 2024, at 9:39 a.m. of Resident 10 in his room sitting in his electric wheelchair revealed an accumulation of dust, dirt and debris on the resident's bed, floor, and in the bathroom. There were three dried-up alcohol wipes, straws, and straw papers scattered about, as well as crumbs and a large amount of generalized dirt 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 clinical records and staff interviews, it was determined that the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for one of 15 residents reviewed (Resident 10). Findings include: The facility's policy regarding dressing and wound documentation, dated July 26, 2024, indicated that wound care/dressings and refusals should be documented on the resident's medical record, treatment sheet, or designated wound form. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated September 1, 2024, revealed that the resident was cognitively intact, required assistance with daily care needs, and had diagnoses that included quadriplegia, drug abuse, and a pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure). Current physician's orders for Resident 10, included an order for the resident's right ischium (pelvis), right iliac crest (hip bone), and right medial buttocks to be cleansed with Dakin's (antiseptic…

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 ensure that proper infection control practices were performed during care for one of 15 residents reviewed (Resident 15). Findings include: The facility's policy regarding perineal care, dated July 26, 2024, indicated that staff was to discard disposable items into designated containers, remove gloves and discard into designated container, wash and dry hands thoroughly, reposition the bed covers, and make the resident comfortable. Observations during wound care on September 11, 2024, at 9:53 a.m. revealed that Wound Care Nurse 2 completed the physician's ordered treatment to the resident's coccyx (tailbone area) wound. The brief that was under the resident was heavily soiled with serosanguineous (blood and serum, the liquid part of blood) drainage. Wound Care Nurse 2 rolled up the soiled brief, placed a clean brief, then rolled Resident 15 onto his left side and removed the soiled brief, which then fell from the bed to the floor. Wound Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies and clinical records, as well as staff and family interviews, it was determined that the facility failed to routinely conduct care plan meetings and invite the resident or representative to attend for one of six residents reviewed (Resident 6). Findings include: The facility's policy regarding assessment/care plans, dated January 10, 2024, revealed that the resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. The resident/representative's right to participate in the development and implementation of his or her plan of care includes the right to participate in the planning process, request meetings, and request revisions to the plan of care. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated June 11, 2024, indicated that the resident was confused, required extensive assistance 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 clinical records and facility assessment reports, as well as staff interviews, it was determined that the facility failed to complete safety assessments for one of six residents reviewed (Resident 4) who used an air mattress. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 15, 2024, revealed that the resident was cognitively impaired, was totally dependent on facility staff with care needs, had multiple pressure ulcers, had a feeding tube, and was at risk for falls. A care plan for Resident 4, dated January 15, 2024, indicated that the resident was at risk for falls related to impaired mobility. Physician's orders for Resident 4, dated January 17, 2024, indicated that she was to have an air mattress with bolsters. A nursing note for Resident 4, dated March 30, 2024, at 4:15 a.m., revealed that the resident was found on the floor lying on her right side. An air mattress assessment was completed on June 6, 2024. A nursing note for Resident 4, dated June 7,…

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

Based on review of established infection control guidelines and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for two of six residents reviewed (Residents 1, 4). 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 infection…

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 medications were followed for two of four residents reviewed (Residents 1, 2), and failed to ensure that verbal phone orders were written and followed for one of four residents reviewed (Resident 1). Findings include: A facility policy for medication administration, dated January 10, 2024, indicated that medications are administered in a safe and timely manner as prescribed. A facility policy for telephone orders, dated January 10, 2024, indicated that verbal telephone orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 2, 2024, revealed that the resident was understood and understands others, required assistance with daily care needs, had a diagnosis of diabetes (a disease causing high blood sugar levels), 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 clinical records and staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications for one of 10 residents reviewed (Resident 2). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 2, 2024, indicated that the resident was cognitively intact, required assistance from staff for all daily care needs, and had diagnoses that included chronic pain. Physician's orders for Resident 2, dated April 12, 2024, included an order for the resident to receive one 5-325 milligram (mg) tablet of Oxycodone/Tylenol (a combination controlled narcotic pain medication) every four hours as needed for pain. Resident 2's controlled drug record (used to keep count of narcotic medication) for April 2024 revealed that the facility received 60 tablets of 5-325 mg Oxycodone/Tylenol. According to the controlled drug log, there were 60 doses of Oxycodone/Tylenol signed out for administration to Resident 2; however, according 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 clinical records, and staff interviews, it was determined that the facility failed to ensure that physicians orders were followed for one of 10 residents reviewed (Resident 5). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated February 22, 2024, revealed that the resident was admitted on [DATE]; was cognitively intact; required substantial to maximum assistance for personal hygiene needs; and had diagnosis that included chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems). A review of discharge instructions from the hospital, dated November 27, 2023, revealed that the resident was to follow up with orthopedics (medical specialty dealing with injures and diseases of the musculoskeletal system) in one to two weeks regarding right shoulder effusion (accumulation of fluid in the joint). There is no documented evidence in the clinical record that 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that medications were provided as ordered by the physician for three of 66 residents reviewed (Resident 7, 64, 97) and failed to ensure that physician orders were followed for one of 66 residents reviewed (Resident 90). Findings include: The facility's medication administration policy, dated January 19, 2023, indicated that medications were to be administered in accordance with prescriber orders, including any required time frame. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated August 7, 2023, indicated that the resident was cognitively intact, required extensive assistance for daily care needs, and had diagnosis that included Parkinson's (disease that affects nerves), hypotension (low blood pressure), and end-stage renal disease. Physician's orders for Resident 7, dated March 24, 2023, included orders for the resident to receive 10 milligrams (mg) of Midodrine (a…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents maintained acceptable parameters of nutritional status by failing to ensure timely notification of the physician for one of 66 residents reviewed (Resident 65). Findings Include: The facility's policy regarding food and nutrition anthropocentric (measurements), dated January 19, 2023, indicated that any resident with a weight change of 5 percent or more since the last weight assessment will be reweighed for confirmation and that interventions would be based on several things. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 65, dated June 26, 2023, revealed that the resident could make himself understood and could understand others, required minimal assistance for personal care needs, and had diagnoses that included anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells) and hemiplegia (muscle…

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 accountability for controlled medications (drugs with the potential to be abused) for one of 66 residents reviewed (Resident 64). Findings include: The facility's policy regarding medications administration, dated January 19, 2023, indicated that the individual administering a medication would record in the resident's medical record the date and time the medication was administered, the dosage, the route of administration, any compliants or symptoms for which the drug was administered, any results achieved and when the results were observed, and the signature and title of the person administering the drug. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 64, dated July 31, 2023, indicated that the resident was cognitively intact, had pain, received pain medications as needed, received an opioid (controlled pain medication) and antianxiety medications, and had diagnoses of…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of anti-anxiety medications for one of 66 residents reviewed (Resident 64). Findings include: The facility's policy regarding medications administration, dated January 19, 2023, indicated that the individual administering a medication would record in the resident's medical record the date and time the medication was administered, the dosage, the route of administration, any compliants or symptoms for which the drug was administered, any results achieved and when the results were observed, and the signature and title of the person administering the drug. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 64, dated July 31, 2023, indicated that the resident was cognitively intact, had verbal behaviors toward others, had diagnoses that included anxiety and received an anti-anxiety…

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 ensure that dietary staff wore hair coverings that completely covered their facial hair during food handling and failed to store and prepare food in accordance with professional standards for food service safety by not dating opened food items and not storing food under sanitary conditions. Findings include: The facility's policy regarding dietary employee personal hygiene, dated January 19, 2023, revealed that all dietary staff must wear hair restraints (e.g., hairnet, hat and/or beard restraint) to prevent hair from contacting food. Observations in the kitchen on November 7, 2023, at 11:34 a.m. revealed that [NAME] 3 was preparing meal trays for lunch and had exposed facial hair; however, he did not have his facial hair covered, and that the Dietary Manager also had exposed facial hair and did not have it covered it while working around the food at lunch time. Interview with the Dietary Manager on November 8, 2023, at 2:30 p.m. confirmed that [NAME] 3 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 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 correction for a State Survey and Certification (Department of Health) surveys ending December 7, 2022; February 4, 2023; July 12, 2023; and August 29, 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 November 9, 2023, identified repeated deficiencies related to accuracy of Minimum Data Sets (MDS), creating and implementing care plans, revision of care plans, quality of care, preventing/treating pressure ulcers, nutrition/hydration status maintenance, tube feeding, pharmacy services, 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.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while providing medications for one of 66 residents reviewed (Resident 79), failed to ensure that proper infection control practices were followed for urinary catheter care for one of 66 residents reviewed (Resident 109), and failed to report COVID positive residents and staff to the Department of Health. Findings include: The facility's policy regarding medication administration, dated January 19, 2023, indicated that staff were to follow established facility infection control procedures (hand washing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications. Observations during medication administration on November 8, 2023, at 8:47 a.m. revealed that Licensed Practical Nurse 4 prepared to administer medications to Resident 79 and obtained Vitamin D from a stock medication bottle (medication used for multiple residents). The nurse touched the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual Minimum Data Set assessments were completed in the required timeframe for four of 66 residents reviewed (Residents 26, 60, 93, 96). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that an admission MDS assessment was to be completed no later than 14 days after admission. An admission MDS assessment for Resident 26 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on October 20, 2023, which was 15 days after admission. An admission MDS assessment for Resident 60 revealed that 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 Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for two of 66 residents reviewed (Residents 23, 60). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to have a completion date (Section Z0500B) that was no later than the ARD plus 14 calendar days. A quarterly MDS assessment for Resident 23 had an ARD of August 14, 2023. There was no previous quarterly or comprehensive MDS assessment completed in the prior 92…

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 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 four of 66 residents reviewed (Residents 30, 51, 60, 97). Findings include: The Long-Term Care Facility RAI User's Manual, dated October 2019, revealed that Section N0415F (Antibiotic Medications) was to be coded with the number of days the resident received an antibiotic medication during the seven-day assessment period. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 30, dated October 26, 2023, revealed that Section N0415F was coded (1), indicating that the resident did receive antibiotics during the seven-day assessment period. Review of the Medication Administration Record (MAR) for Resident 30 revealed that the resident did not receive antibiotics during the seven-day look back period. Interview with the Director of…

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

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for two of 66 residents reviewed (Residents 23, 30). Findings include: A facility policy for Comprehensive Person-Centered Care Plans, dated January 19, 2023, included that the interdisciplinary team in conjunction with the resident and his or her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive person-centered care plan is developed within seven days of the completion of the required comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). A Quarterly MDS assessment for Resident 23, dated August 27, 2023, revealed that the resident was cognitively intact, required extensive assistance for personal care needs, and had diagnoses that included atrial fibrillation (an irregular and often rapid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 66 residents reviewed (Residents 90, 121). Findings include: A facility policy for Comprehensive Person-Centered Care Plans, dated January 19, 2023, included that assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change. A quarterly MDS assessment for Resident 90, dated August 3, 2023, revealed that the resident was cognitively impaired, was dependent on staff for personal care needs, was receiving dialysis, and had diagnosis that included end-stage renal disease. Observations of Resident 90 on November 9, 2023, at 1:30 p.m. revealed that the resident resting in a low positioned bed with fall mats on both sides of his bed. Interview with The Director of Nursing on November 9, 2023, at 1:35 p.m.…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation and failed to administer treatments per physician's orders for one of 66 residents reviewed (Resident 74). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 74, dated October 13, 2023, revealed that the resident was cognitively impaired, was dependent on staff for daily care needs, had two Stage 4 pressure ulcers (full thickness tissue loss with exposed bone, tendon or muscle) and an unstageable deep tissue injury. The resident's care plan, revised on November 1, 2023, included that the resident had pressure ulcers and treatments were to be administered as ordered by the physician. Physician's orders for Resident 74, dated October 17, 2023, included orders to cleanse his left elbow with wound cleanser, pat dry, apply collagen sheet (wound dressing), and cover with a small border dressing every day shift and as needed. Physician's orders, dated…

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

Based on review of clinical record reviews and facility policies, 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 66 residents reviewed (Resident 51). Findings include: The facility's policy for mouth care, dated January 19, 2023, stated that oral care was provided to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and prevent oral infection. Documentation in resident's clinical record was to include the date and time the mouth care was provided and the name and title of the individual who provided the care. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated September 20, 2023, revealed that the resident was cognitively intact, required extensive assist with daily care needs including mouth care, was to have nothing by mouth, and had a feeding tube (a tube surgically implanted 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 clinical records and staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 66 residents reviewed (Residents 81). Findings Include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 81, dated May 24, 2023, revealed that the resident was cognitively intact, was independent with daily care needs, and had diagnoses that included diabetes. Physician's orders for Resident 81, dated January 1, 2023, included an order for insulin aspart, inject 10 units subcutaneously (under the skin) each morning with breakfast. A review of the Medication Administration Record (MAR) for Resident 81 revealed that on October 22, 2023, and October 24, 2023, administration was documented as vitals outside of parameters for administration. A review of the nurse's notes for Resident 81 revealed there was no documentation for physician notification. Interview with Director of Nursing on November 8, 2023, at 12:25 p.m. confirmed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, it was determined that the facility failed to ensure that the resident environment was maintained in a homelike manner in the hallways on the [NAME] nursing unit. Findings include: Observations of hallway on the [NAME] nursing unit on October 3, 2023, at 9:10 a.m. and at 2:05 p.m. revealed that multiple ceiling tiles near resident rooms [ROOM NUMBERS] contained large brown spots. One ceiling tile by a large vent in the center of the ceiling contained a brown spot as well as a black spotted substance and a smaller vent in the ceiling that also contained a black spotted substance. Interview with the Director of Maintenance on October 3, 2023, at 2:05 p.m. confirmed that the above areas on the [NAME] nursing unit by resident rooms [ROOM NUMBERS] could be cleaned. He indicated that there is an air conditioning unit on the roof above the brown and black areas, and on hotter days the air conditioning unit will develop condensation, which then drips down onto the ceiling…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of nine residents reviewed (Resident 1). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 23, 2023, indicated that the resident was understood and able to understand others, required extensive assistance from staff for daily care needs, was dependent on staff for transfers and bathing, and it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. A care plan, dated August 16, 2023, revealed that Resident 1 preferred a shower and was to be showered on Wednesday during the 3:00 to 11:00 p.m. shift. Bathing documentation for August 30 through September 26, 2023, indicated that Resident 1 was to receive a shower during the evening shift on Wednesday. There was no documented evidence that the resident received a shower on September 20 and 27, 2023. 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 facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address an allergy to bees for one of eight residents reviewed (Resident 8). Findings include: The facility's policy regarding care plans, dated January 19, 2023, indicated that care plans would incorporate goals and objectives that lead to the resident's higher obtainable level of independence. Care plan goals and objectives were defined as the desired outcome for a specific resident problem. A nursing note, dated August 21, 2023, at 2:39 p.m. revealed that the resident was admitted to the facility. An allergy list for Resident 8, undated, revealed that the resident was allergic to bees. Physician's orders for Resident 8, dated August 21, 2023, included orders for the resident to receive 0.3 milligrams (mg) of epinephrine (used treat a severe, potentially life-threatening allergic reaction) solution intramuscularly (injected into the muscle) every 24 hours as…

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.