Kadima Rehabilitation & Nursing At Harmony

Based on review of observations and staff interview, it was determined that the facility failed to protect and value residents' private space (South Wing Resident R18, and R63) Findings include: Review of the facility policy Confidentiality dated 4/25/25, indicated that to protect resident's privacy and dignity, the staff should not enter rooms without knocking except in an emergency. During an observation on South Wing on 5/5/25, at 12:03 p.m. Nurse Aide (NA) Employee E1 was seen entering Resident 18's room without knocking or requesting permission to enter. During an observation on South Wing on 5/5/25, at 12:05 p.m. Nurse Aide (NA) Employee E1 was seen entering Resident 63's room without knocking or requesting permission to enter. During an interview on 5/5/25, at 12:05 p.m. NA Employee E1 confirmed that she failed to knock prior to entering Resident R18, and R63's rooms which failed to protect and value the residents' private space. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 201.29(a)Resident Rights.

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of five medication carts (North Medication Cart). Findings include: Review of facility policy Confidentiality dated 4/25/25, indicated the resident has the right to personal privacy and confidentiality of his or her personal and clinical records. Access to resident medical records will be limited to the staff and consultants providing services to the resident. During an observation on 5/6/25, at 11:20 a.m. the North Medication Cart at the nurses station was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. During an interview on 5/6/25, at 11:20 a.m. Registered Nurse Employee E4 confirmed the above observation and that the facility failed to maintain the confidentiality of residents' medical information as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.29(c.3) 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 observation, and staff interview, it was determined that the facility failed to maintain a clean, safe, and homelike environment for three of ten residents (Resident R106, R102, and R64). Findings Include: Review of the facility policy Resident Environment dated 4/25/25, indicated the facility will provide a safe, clean, comfortable, and homelike environment. During observations of the North nursing unit on 5/5/25, at 9:45 a.m. the following was observed: -Resident R106 in room [ROOM NUMBER]-D, indicated the perimeter of the wall to the left of the entrance door was dirty with built up grime, the floor mat beside the bed was dirty with white and gray markings and smudges, the perimeter of the wall under the heating element was corroded with built up grime, the bathroom had five visibly cracked floor tiles. -Resident R102 in room [ROOM NUMBER]-D, indicated a bathroom with three visibly cracked floor tiles around the base of the commode. -Resident R64 in room [ROOM NUMBER]-B, indicated gnats flying around…

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, facility provided documents, clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from mental abuse and threats of punishment or deprivation for one of three residents reviewed (Resident R64). Findings include: The facility's policy Abuse Protection dated 4/25/25, indicated each resident has the right to be free from abuse. Abuse means the infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation, denial of food or privileges. Review of admission record indicated Resident R64's was admitted to the facility on [DATE]. Review of Resident R64's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/18/25, indicated the diagnoses of chronic atrial fibrillation (irregular heart rhythm), mechanical complications of an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident records, facility documentation, incidents submitted to the local State field office, resident council interview, resident and staff interviews it was determined that the facility failed to submit a report of an allegation of emotional abuse in a timely manner to the local State field office for one of five sampled residents (Resident R96). Findings include: The facility Abuse reporting and investigation policy dated 11/1/24 and last reviewed 4/25/25, indicated that the facility will thoroughly investigate all reports of suspected or alleged abuse. Abuse includes the deprivation by an individual of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Mental abuse includes humiliation, harrassment, threats of punishment, or deprivation. Department of Health will be notified of an alleged event by the Administrator. Review of Resident R96's admission record indicated that he was originally admitted on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of three residents sampled with facility-initiated transfers (Residents R3, and R110). Findings include: Review of the admission record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/28/25, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and hyperlipidemia (high levels of fat in the blood). Review of the clinical record indicated Resident R3 was transferred to the hospital on 4/28/25. Review of Resident R3's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced…

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, observation and interviews it was determined that the facility failed to provide care and services to meet the accepted standards of clinical practice two of four residents (Resident R14 and R16). Findings include: A review of the facility policy Controlled Medications dated 4/25/25, indicated when a controlled drug is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record: date and time of administration, amount administered, signature of the nurse administering the dose, completed after the dose is actually administered. Observation of medication storage on 5/7/25, at 12:42 p.m. of the North Medication Cart, it was discovered that the random narcotic count for accurate record keeping was inaccurate. Interview on 5/7/25, at 12:43 p.m. Licensed Practical Nurse (LPN) Employee E6 indicated, the count is not going to be correct, because I gave the medications this morning. I signed them on 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 facility policy, clinical records, and staff interview it was determined that the facility failed to follow a physician order for an edema (swelling) glove for one out of three residents (Resident R35). Findings include: Review of the facility policy Quality of Care: Attain and Maintain dated 4/25/25, indicated each resident must receive and the facility will provide the necessary services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Review of the admission record indicated Resident R35 was admitted on [DATE]. Review of Resident R35's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/29/25, indicated the diagnoses of high blood pressure, stroke (damage to the brain from an interruption of blood supply), and seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness). Review of Resident R35's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records and resident and staff interviews, it was determined that the facility failed to make certain that residents receive proper treatment and assistive devices to maintain visual ability for one of four residents (Resident R41). Findings include: Review of the facility policy Vision and Hearing dated 4/25/25, indicated the facility will ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities. Interview on 5/6/25, at 9:40 a.m. Resident R41 asked survey agency to read the menu for lunch as he could not read it. Resident indicated he used to have glasses but has not had a pair in a long time. Review of the admission record indicated Resident R41 was admitted to the facility on [DATE]. Review of Resident R41's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/12/25, indicated the diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one of five residents (Resident R2). Findings include: Review of facility policy Splint/Brace Management dated 4/25/25, indicated residents will be assessed to determine a splint/brace device program to attain, maintain, and prevent decline in joint mobility. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/30/25, indicated diagnoses of high blood pressure, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), and muscle weakness. Review of a physician order dated 1/31/25, indicated resident to wear bilateral (both sides) palm roll splints (a brace…

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, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for two of two residents (Residents R11 and R89). Findings include: Review of facility policy Side Rails Proper Use dated 4/25/25, indicated an assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's bed mobility and ability to transfer between positions, to and from bed or chair, to stand and toilet. The use of quarter or half-side rails, as an assistive device will be addressed in the resident care plan. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE]. Review of Resident R11's Minimum Data Set (MDS - a periodic assessment of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident records, a facility tour, and staff interview it was determined that the facility failed to follow transmission based precautions and utilize enhanced barrier precautions (EBP) creating the potential for cross contamination for two out of five sampled residents (Residents R79 and R92). Findings include: The facility Infection control policies and procedure: enhanced barrier precautions policy dated 4/1/24 and last reviewed 4/25/25, indicated that enhanced barrier precautions are an infection control intervention designed to reduce transmission of multi-drug resistance organisms (MDRO) in nursing homes. Enhanced barrier precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those with increased risk such as residents with wounds or indwelling medical devices. Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheostomies. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policy and resident and staff interviews, it was determined that the facility failed to follow the policies established to assess one of twelve residents for safe smoking practices (Resident R64). Findings include: Review of the facility Smoking Policy dated 4/25/25, stated (1) upon admission, residents who smoke will be reviewed for safety with independence in smoking (2) licensed staff or department managers will be responsible for completion of the resident smoking review upon admission(3) All smoking will be . (5) All smokers who are capable of understanding the rules and regulations will be asked to sign a smoking agreement to demonstrate their understanding of the rules concerning smoking. (7) smokers will be reviewed on admission, quarterly and as necessary depending on individual circumstances and changes in the resident's condition. Review of the admission record indicated Resident R64 admitted to the facility on [DATE]. Review of Resident R64's Minimum Data…

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, shower schedule documents, resident clinical records, resident and staff interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of seven sampled residents (Resident R1). Findings include: The facility Flow of care policy dated 2/1/24, indicated that care will be provided to residents, as needed 24-hour a day to attain and maintain the highest level of functioning. The flow of care is to be implemented on a continuous basis to promote quality of life with the resident. The provision of targeted care needs shall be documented on Care Tracker (electronic record), Point of Care (electronic record), or ADL (Activity of Daily Living) Flow Records. The 7 a.m. -3 p.m. shift may provide the following: oral hygiene, toileting, breakfast, and showers/baths. The 3 p.m.- 11 p.m. shift may provide the following: Evening meal, repositioning, hydration, and bath/showers. Review of facility shower schedule documentation indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify the physician of missed medication and increased behaviors for one of four residents (Resident CRR2) and failed to notify a resident's responsible party for an increase in medication dosage for one of three residents (Resident R1). Review of the facility's policy Notification Change in Condition Responsible Party dated 2/1/24, indicated the responsible party or guardian is to be notified of changes in condition or occurrences to ensure that the resident ' s responsible party or guardian is notified of changes and /or occurrences and action and pertinent information are documented. When any one of the following instances occurs, the resident's responsible party or guardian will be notified including but not inclusive to: There is a significant change in the resident's physical, mental or psychosocial status. An incident has occurred, (including falls, altercations, injuries, elopements,…

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, clinical records, observations, and staff interviews it was determined that the facility failed to make certain each resident received adequate supervision which resulted in one elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of four residents (Resident CRR2) and failed to consistently document in the clinical record regarding post-incident response after an elopement for two of four residents (Resident R1 and CRR2). Findings include: Review of the facility's policy Elopement Prevention dated 2/1/24, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Review of the facility's policy Notification Change in Condition Responsible Party dated 2/1/24, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to obtain a physician's order for a discharge and make certain that the necessary resident information was communicated to the receiving health care provider for one out of five residents sampled with facility-initiated transfers (Resident R1). Findings include: Review of facility policy Documentation of Resident Discharge dated 2/1/24, indicated that documentation will be completed when a resident is discharged form this facility. The following items are to be documented when a resident is discharged from the facility to home or another facility: - Resident current condition, including mental status - Physician's discharge order has been obtained - Transfer form, facesheet, history, and physical - Physician current orders and completed testing Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs)…

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 documents and staff and resident interview it was determined that the facility failed to resolve concerns for 2 of 2 resident's reviewed. Findings include: Review of Resident R2's admission record indicated she was originally admitted on [DATE], with diagnoses that included anxiety, osteoarthritis and difficulty walking. Review of Resident R2's quarterly Minimum Data Set(MDS-a periodic assessment of care) dated 5?10/24 indicated diagnosis remain current. Interview for Mental Status (BIMS a screening test that aides in detecting cognitive function. The BIMS total score suggests the following distributions: 13-15 cognitively intact 8-12 moderately impaired 0-7 severe impairment Resident R1's score was 15- cognitively intact Review of facility documentation indicated Resident R2's had a grievance on 5/31/24. She stated she did not get care. The facility resolution was to put a white board in Resident R2's room with who her nurse and nurse aide for the day. Interview on 6/27/24 at 12:35…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview it was determined that the facility failed to follow a physician order for one of seven residents (Resident R1). Findings include: Review of Resident R1's admission record indicated he was originally admitted on [DATE], with diagnoses that included neuromuscular dysfunction of bladder, major depressive disorder and muscle weakness. Review of Resident R1's quarterly MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 6/15/24, indicated that the diagnoses were current upon review. Review of Resident R1's physician order's dated 5/17/24 indicated to administer Ferrous Gluconate Oral Tablet 324 (38 Fe) MG (Ferrous Gluconate) give 324 mg by mouth one time a day for anemia. Review of Resident R1's physician order's dated 5/17/24 indicated to administer Protonix Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium)give 1 tablet by mouth one time a day for GERD. Review of Resident R1's physician order's dated 5/17/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility menu, facility documents, observations, staff interviews, and resident interview, it was determined that the facility failed to comply with food safety regulations by failing to monitoring the proper cooling of foods for two days (4/27/24, and 4/28/24), and properly store utensils for one of two ice machines (Main Dining Room) creating the potential for food borne illness. Findings include: Review of the facility policy Food Temperature Recording Policy dated 2/1/24, indicated that temperatures of un-served/production foods will be taken after meal service/production and followed for six hours (if needed) after service/production for appropiate cooling. All temperature's will be recorded on the Cooling Log. Temperatures of un-served/production foods will be taken prior to the close of the Dining Services department for appropriate cooling and will be recorded on the Cooling Log. If the desired temperature of the un-served/production food is not achieved prior to the close of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide documentation of advanced directives or given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for eight of eight residents reviewed (Resident R8, R30, R50, R67, R75, R86, R87, and R311). Findings include: A review of the facility policy Advanced Directives last reviewed [DATE], indicated that the facility has policies and procedures which allow the withholding of CPR (Cardiopulmonary Resuscitation - emergency life-saving procedure that is done when breathing or a heartbeat has stopped) measures from individual residents who have an Advanced Directives stating they do not want to be resuscitated. The procedures for determining when the services may be withheld must respect the resident ' s rights of self-determination. This nursing home will inform the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five out of seven residents sampled with facility-initiated transfers (Residents R30, R57, R59 R75, and R87). The findings include: Review of Resident R30's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R30's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/2/24, indicated diagnoses of hypertension (high blood pressure in the arteries), multiple sclerosis (a disease that affects central nervous system), and seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). Review of Resident 30's clinical record revealed that the resident was transferred to the hospital on 4/27/24 and returned to the facility on 4/27/24, same day. Review of Resident R30's clinical record revealed no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident/resident representative and/or the representative of the Office of the State Long-Term Care Ombudsman of resident transfers, in writing, to include to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman for five of seven resident records reviewed (Resident R30, R57, R59, R75, and R87) Findings Include: Review of Title 42 Code of Federal Regulations §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged ; (iv) A statement of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for three of six sampled residents (Resident R3, R21, and R37). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated indicated the following instructions: Section K - Swallowing/Nutritional Status: base weight on the most recent measure in the last 30 days. If the last recorded weight was taken more than 30 days prior to the Assessment Reference Date (ARD) of this assessment or previous weight is not available, weigh the resident again. Section O-Hospice care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for 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 facility policies and job descriptions, clinical records, and staff interviews, it was determined that the facility failed to adhere to acceptable standards of practice related to participation in interdisciplinary meetings for 12 of 12 months, and completion of Nutrition Assessments by the Registered Dietitian for two of eight residents reviewed (Residents R21 and R59). Findings include: The Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards: Responsibilities of the Licensed Dietitian/ Nutritionist Section 21.711 Professional Conduct indicated that the Licensed Dietitian/ Nutritionist shall provide information which will enable patients to make their own informed decisions regarding nutrition and dietetic therapy, including the reasonable expectations of the professional relationship. Review of facility policy Resident Weights, dated 2/1/24, indicated that the facility will identify residents at risk for significant weight change and ensure uniform tracking 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 facility policy, clinical record review, a resident council group interview, resident and staff interviews, it was determined that the facility failed to make certain that showers were consistently provided and failed to provide adequate hygienic care for eight out of 12 sampled residents (Resident R30, R50, R63, R67 R75, R87, R311, and R312 ). Findings include: The facility Flow of care policy dated 2/1/24, indicated that residents are to have two baths or showers per week unless the resident states otherwise. Review of Resident R30's clinical record indicated she was admitted to the facility on [DATE]. Review of Resident R30's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/2/24, indicated diagnosis of hypertension (high blood pressure in the arteries), multiple sclerosis (a disease that affects central nervous system), and seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures. Review of Resident R30's care plans…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, facility documents and staff interview, it was determined that the facility failed to ensure that residents received neurological assessment after an incident involving a fall for four of nine residents (Residents R8, R12, R30, and Resident R87). Findings include: Review of facility policy Falls Protocol dated 2/1/24, indicated residents experiencing an actual fall will have an immediate assessment by nursing and medical attention will be obtained as needed. Falls that involve a possible head injury will have neurological checks performed and documented. Review of facility policy Neurological Checks dated 2/1/24, indicated neurological checks shall be performed following an unwitnessed fall or known head injury. Neurological checks should be performed periodically for at least 72 hours. Neurological checks shall be documented on the designated record. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that weights were monitored for two of nine residents (Resident R21, and R50), failed to timely assess the nutritional status for two of four residents (Resident R21, and R59), and failed to provide nutritional supplements as ordered for weight loss for one of two residents ( Resident R50). Findings include: Review of facility policy Resident Weights, dated 2/1/24, indicated that the facility will identify residents at risk for significant weight change and ensure uniform tracking and reporting of resident weights. Monthly weights will be obtained weekly times four weeks following admission/readmission and monthly thereafter. The licensed nurse will notify the Interdisciplinary Team for further assessment. Review of facility policy Nutriton Management, dated 2/1/24, indicated that based on a resident's comprehensive assessment, the facility will ensure that a 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 policy, observations, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care and maintain respiratory equipment for three out of four sampled residents (Resident R3, R12, and R66). Findings include: The facility Oxygen administration policy dated 2/1/24, indicated that humidifiers should be labeled and dated with the time changed. At regular intervals, check and clean oxygen equipment, masks, tubing and nasal cannula. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/11/24, indicated active diagnosis of high blood pressure, dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), and muscle weakness. Review of a physician order dated 1/2/24, indicated to administer supplemental oxygen continuously at 2 liters per minute via a nasal cannula (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 staff interviews, and review of the Food Service Director's Job description, it was determined that the facility failed to employ a full-time qualified Food Service Director for six of six months (November and December 2023, and January through April 2024). Finding include: Review of the facility's Food Service Director's Job Description indicated that the Food Service Director: · Must be a graduate of an accredited course in dietetic training approved by the American Dietetic Association. · Must be registered as a Food Service Director in Pennsylvania. · Must provide documentation of registry/certificate upon application for the position. During an interview conducted at initial tour on 4/29/24, at 9:28 a.m. Food Service Director (FSD) Employee E9, stated that he was not a Certified Dietary Manager (CDM) and did not have any formal education or certificates in food service management. FSD Employee E9 stated that he has been a cook in the facility, but was promoted to FSD about six months ago. FSD Employee E9 also clarified that he is not currently enrolled in any classes…

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, facility policies, facility documents, and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential clinical duties for six out of 12 months (November and December 2023, and January through April 2024). Findings include: Review of facility policy Resident Weights, dated 2/1/24, indicated that the facility will identify residents at risk for significant weight change and ensure uniform tracking and reporting of resident weights. Monthly weights will be obtained weekly times four weeks following admission/readmission and monthly thereafter. The licensed nurse will notify the Interdisciplinary Team for further assessment. Significant weight loss is defined as: 5% or greater in one month 7.5% or greater in three months 10% or greater in six months. Review of Registered Dietitian's Job Description revealed that the purpose of Registered Dietitian's job position is to implement, coordinate and evaluate the medical nutrition…

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, facility documents, resident interviews, meal tray observations and staff interviews, it was determined that the facility failed to provide menu selections according to the resident's preference for five out of nine residents (Resident R21, R58, R59, R88, and R210). Findings include: Review of the facility policy Meal Service Line last reviewed on 2/1/24, indicated that the cook will be stationed at the steam table to place foods from the wells onto the plate in accordance with the menu and resident diet order. Dining Services staff will check the tray for accuracy, cover the plate, and place the tray onto the food cart to be delivered to the floor or unit. The meal service line will be supervised and checked for quality assurance by the Dining Service Manager, Assistant Manager, Supervisor, or Dietitian. Review of facility Grievance Log dated 3/12/24, revealed that a resident voiced concern as no one had discussed food preferences with the resident. Review of 3/12/24,…

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 in-service documentation, personnel records, and staff interviews it was determined that the facility failed to implement and maintain an effective training program for six out of eight personnel records (LPN Employee E11, LPN Employee E12, Nurse aide Employee E7, Nurse aide Employee E13, Nurse aide Employee E14, and Nurse aide Employee E15). Findings include: The facility Monthly mandatory education schedule last reviewed 2/1/24, indicated that staff will be provided annual inservice training based on the following: January training (abuse, neglect, elder care justice act) February training (infection control, bloodborne pathogens, COVID-19). March training (psychosocial needs, dementia, trauma informed care, substance abuse). April training (customer service). May training (resident rights, HIPAA/confidential information, cultural diversity). June training (falls, restraints, accident, incidents) July training (fire and safety, disasters, hazards, active shooter). August training (restorative care, dietary and nutrition, hydration). September (abuse,…

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 in-service documentation, personnel records, and staff interviews it was determined that the facility failed to ensure that nurse aide staff received annual inservice training on resident rights for four out of four personnel records (Nurse aide Employee E7, Nurse aide Employee E13, Nurse aide Employee E14, and Nurse aide Employee E15). Findings include: The certified nursing assistant job description, last reviewed on 2/1/24, indicated that Nurse aides must complete 12 hours of in-service training annually tracked from date of hire. Nurse aides attend mandatory inservice trainings that includes resident rights. Review of Nurse aide (NA) Employee E7's personnel record indicated she was hired on 12/18/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E7's personnel record did not include annual inservice training on resident rights. Review of Nurse aide (NA) Employee E13's personnel record indicated she was hired on 10/28/91. The record indicated she last received in-service training on 2/2023.…

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

Based on review of facility in-service documentation, personnel records, and staff interviews it was determined that the facility failed to ensure that all nurse aide staff received a minimum of twelve hours of inservice education training each year for four out of four personnel records (Nurse aide Employee E7, Nurse aide Employee E13, Nurse aide Employee E14, and Nurse aide Employee E15). Findings include: The certified nursing assistant job description, last reviewed on 2/1/24, indicated that Nurse aides must complete 12 hours of in-service training annually tracked from date of hire. Review of Nurse aide (NA) Employee E7's personnel record indicated she was hired on 12/18/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E7's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year. Review of Nurse aide (NA)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and staff interviews, it was determined the facility failed to notify the physician of a change in condition for one of six residents. (Resident R30). Findings include: Review of facility policy Notification of Changes dated 2/1/24, indicated the facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: - An accident involving the resident which results in injury and has the potential for requiring physician intervention. - A significant change in the resident ' s physical, mental, or psychosocial status - A need to alter treatment significantly. Review of facility policy Protocol When to Call Physician dated 2/1/24, indicated the physicians caring for residents in your facility was to respond in an appropriate and timely manner to changes in condition as determined by the nursing staff and to address any concerns voiced by staff,…

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, clinical record review, staff interview, and facility submitted documents, it was determined that the facility failed to provide services to create an environment free from neglect for one of four residents (Resident R99). Findings include: Review of facility policy Abuse: Protection From Abuse dated 2/1/24, indicated residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety adequate, and appropriate services, treatment of care, including but not limited to: nutrition, medication, therapies, and activities of daily living. Review of the clinical record indicated Resident R99 was admitted to the facility on [DATE]. Review…

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

Based on review of facility policy, newly hired personnel records and staff interviews it was determined that the facility failed to conduct an FBI background check on an employee prior to working on the nursing unit for one out of five personnel records (Registered Nurse Employee E6) and failed to properly screen an employment by completing a State background check prior to hire for one out of five personnel records (Dietary Aide Employee E17). Findings include: The facility Abuse: Protection from Abuse policy dated 1/23/23 and 2/1/24, indicated that the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. The facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegation of potential or actual abuse and neglect. Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating…

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, resident clinical record, reports submitted to the State, and staff interview it was determined that the facility failed to report two allegations of abuse for one of three sampled residents (Resident R67). Findings include: The facility Abuse:Protection from Abuse policy dated 1/23/23 and 2/1/24, indicated that the resident have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. The facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse or neglect. The facility Abuse Reporting and Investigation policy dated 1/23/23 and 2/1/24, indicated that the facility will thoroughly investigate all reports of suspected or alleged abuse (mental, physical, sexual, involuntary seclusion or misappropriation of resident property), neglect or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, reports submitted to the state, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse for one of three residents (Resident R67). Findings include: The facility Abuse: Protection from Abuse policy dated 1/23/23 and 2/1/24, indicated that the resident have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. The facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse or neglect. The facility Abuse Reporting and Investigation policy dated 1/23/23 and 2/1/24, indicated that the facility will thoroughly investigate all reports of suspected or alleged abuse (mental, physical, sexual, involuntary seclusion or misappropriation of resident property), neglect or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, clinical records, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of seven resident hospital transfers (Resident R57). Findings Include: Review of the admission Packet which is provided to residents upon admission, it was indicated that before the facility transfers a resident to the hospital or the resident goes on therapeutic leave, the facility shall provide written notice to Resident or Resident Representative. Review of the clinical record indicated Resident R57 was admitted to the facility on [DATE]. Review of Resident R57's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/8/24, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), hypertension (high blood pressure in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, resident observation, and staff interviews, it was determined that the facility failed to follow physician's orders for one of two residents (Resident R311). Findings include: Review of facility policy, Medication and Treatment Orders, dated 2/1/24 indicate each medication administered will have a corresponding and complete physician ' s order. Review of facility policy, Treatment and services, dated 2/1/24 indicate based on the comprehensive assessment of a resident, the facility must ensure that a resident is given the appropriate treatment and services to maintain or improve his or her abilities. Review of Resident R311's clinical record indicated he was admitted to the facility on [DATE]. Review of Resident R311's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 4/24/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), hypertension (high blood pressure in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records and staff interview it was determined that the facility failed to obtain laboratory results and promptly report those results as per order for one out of two sampled residents (Resident R17). Findings include: The facility Laboratory services policy dated 8/2016, and last reviewed 2/1/24, indicated that laboratory studies will be obtained only when ordered by a physician. The facility will notify the physician of the results promptly and laboratory findings will be filed in the resident record. The facility will have a system to reconcile physician orders, lab orders, and results received. Review of Resident R17's admission record indicated she was admitted on [DATE]. Review of Resident R17's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 4/10/24, indicated she had diagnoses that included major depressive disorder (a state of consistent sadness and loss of interest interfering in daily life…

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

Based on observations, facility menu, resident interviews, and staff interviews it was determined that the facility failed to follow the displayed menu for one of four observed meals (lunch meal 4/30/24). Findings include: During an interview on 4/29/24, at 12:19 p.m. Resident R59 stated that she often does not receive food items that are on her meal ticket or menu. Review of lunch menu for 4/30/24 revealed that the vegetable was to be broccoli cuts, and that the alternative vegetables were peas, green beans, and carrots. During an observation in the Main Dining Room on 4/30/24, at 12:46 a.m., no residents were served broccoli, but had Winter Blend vegetables (cauliflower, carrots and broccoli) instead. Review of Resident R9, R17, R21, R58, and R210's meal tickets all indicated that they were to have received broccoli cuts, but received Winter Blend instead. During an interview on 4/30/24, at 1:00 p.m. Food Service Director (FSD) Employee E9 stated that he was aware that broccoli was on the menu but that he did not receive it in the food delivery so he served the Winter Blend…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, observation, resident interview, and staff interview, it was determined that the facility failed to serve food products that appeared palatable for one of four meals observed (lunch meal on 4/29/24). Findings include: Review of facility policy Meal Service Line, dated 2/1/24, indicated that the facility will serve food that will be prepared by methods that conserve nutritive value, flavor, and appearance, and will be placed on trays in an attractive manner. During an observation on 4/29/24, at 12:19 p.m. Resident R59 had her lunch tray in front of her, but was not eating. During an observation on 4/29/24, at 12:19 p.m., Resident R59's meal ticket stated that she was to have received fried chicken, however, there was no fried chicken on her tray and there was a very dry, hard, and stringy appearing piece of meat. During an interview on 4/29/24, at 12:20 p.m. Resident R59 was asked what her entrée was and she replied, I think it's left over roast beef from yesterday. During an…

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

Based on facility policy, observation, and staff interview it was determined that the facility failed to properly contain and dispose of garbage in one of one outside dumpsters to prevent the potential for rodent and insect infestation. Findings include: Review of facility policy Garbage and Rubbish Disposal Policy, date 2/1/24, indicated that outside dumpsters provided by the garbage pick-up services must be kept closed and free of litter around the dumpster area. During an observation of the facility's outdoor trash receptacle on 4/29/23, at 9:32 a.m. revealed the lids/covers were not closed on the dumpster. During an interview on 4/29/24, at 9:32 a.m. Food Service Director Employee E9 confirmed that the facility failed to properly contain and dispose of garbage in the outside trash receptacles to prevent the potential for rodent and insect infestation. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 207.2(a) Administrator's responsibility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to maintain and complete accurate documentation for two of nine residents (Resident R3 and R12). Findings include: Review of facility policy Documentation dated 2/1/24, indicated nursing documentation will provide accurate reflection of a resident condition that will meet federal and state requirements. Review of Title 42 Code of Federal Regulations (CFR) §483.709(i) Medical records. In accordance with accepted professional standards and practice, the facility must maintain medical records that are complete, accurately documented, readily accessible, and systematically organized. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/11/24, indicated active diagnosis of high blood pressure, dementia, and muscle weakness. Review of a physician order dated 1/2/24, indicated to weigh patient…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, resident clinical records, and staff interviews, it was determined the facility failed to obtain a physician order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for one of four residents (Resident R30). Findings include: Review of the facility's Hospice Care Policy dated, 2/1/24, indicated hospice care will be offered to residents, as ordered by the attending physician, to provide additional supportive care for residents with end-stage terminal illnesses. Social services or designee will obtain a physician ' s order and contact Hospice Agency. All hospice services are provided under contractual arrangements. Review of Resident R30's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R30's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/2/24, indicated diagnoses of hypertension (high blood pressure…

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

Based on policy review, observations, and staff interview, it was determined that the facility failed to maintain a clean, comfortable, homelike environment in seven out of 12 sampled resident rooms (Residents R1, R2, R3, R4, R5, R6, and Resident R7). Findings include: The facility Resident environment policy last reviewed 2/1/24, indicated that the facility will provide an environment that is safe, clean, comfortable and homelike. During a tour with of the facility on 2/26/24, starting at 10:08 a.m. with Environmental services/housekeeping supervisor Employee E1, the following was observed: At 10:08 a.m. Resident R1's room was observed with white chips and gauges along the wall behind his bed. At 10:10 a.m. Resident R2's room was observed with white chips and gauges along the wall behind his bed. staining around the bathroom commode, and brown stains on the corners of the floor. At 10:14 a.m. Resident R3's room was observed with a white dresser. At the bottom of white dresser was frayed and sharp edges with the potential to lacerate oneself. At 10:16 a.m. Resident R4's room 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 a review of facility policies, documents, resident council minutes and staff interviews it was determined that the facility failed to implement the grievance process in accordance with Federal regulations for five of five residents (Resident R4, R5, R6, R7, and R8). Findings include: Review of the facility policy Resident Rights reviewed 11/1/23, indicated the facility will protect and promote the rights of each resident. It stated a resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. It was indicated residents have the right to have grievances promptly resolved, in accordance with law. Review of the facility resident council meeting minutes dated 1/9/24, indicated to maintain the integrity of confidentiality, this month's resident council was performed 1:1. It was indicated there were concerns identified regarding staff being rude, failing to answer call lights in a timely manner, and assist a resident back to bed. Review of a grievance…

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, resident observations, resident interviews and confidential staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of seven of ten residents (Resident R2, R4, R5, R6, R7, R8, and R9). Findings Include: Review of the undated, Certified Nursing Assistant job description indicated it is the responsibility of nurse aides to assist residents with bath functions, nail care, and bladder and bowel functions. During an interview on 1/24/24, at 9:57 a.m. Nurse Aide (NA), Employee E17 stated there can be an improvement with staffing. She stated she is unable to provide care to the residents and is often overwhelmed. It was indicated she has worked as a nurse aide for 30 years and it hasn't been this bad. During an interview on 1/24/24, at 10:03 a.m. NA, Employee E18 stated we can always use staff and the weekends are worse. NA, Employee E18 stated resident's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical record, investigation documentations, resident and staff interviews, it was determined that the facility failed to report an allegation of neglect within 24 hours for one out of four sampled residents (Resident R2). Findings include: The facility policy Abuse: Protection From Abuse dated 6/23, reviewed 11/1/23, indicated residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect. Regardless of how minor an accident or incident may be, including injuries of unknown source, an investigation must be implemented and witness statements are obtained. An Accident or Incident Report Form must be completed for all reported accident or incidents. It stated neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely,…

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, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate allegations of abuse or neglect for two of five residents reviewed (Resident R2 and Resident R3). Findings include: The facility policy Abuse reporting and Investigation dated 8/16, reviewed 11/1/23, indicated the facility will thoroughly investigate all reports of suspected or alleged abuse, neglect, or exploitation. Injuries of unknown origin will be investigated to rule out potential abuse. It stated anyone who witnesses an incident of suspected resident abuse or neglect is to report it to the charge nurse or supervisor immediately. The facility policy Accidents and Incidents-Investigating and Recording dated 8/16, reviewed 11/1/23, indicated all accidents or incidents occurring on our premises must be investigated and reported to the administrator. It stated regardless of how minor an accident or incident, including injuries of unknown origin, it must…

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, clinical records, and staff interview it was determined that the facility failed to provide wound dressing treatment as ordered for one out of two residents (Resident R6). Findings include: Review of the facility Medication Administration policy dated 8/20, last reviewed 11/1/23, indicated topical medications used in treatments are listed on the E-TAR/E-MAR (electronic treatment administration record and electronic medication administration record). Review of the facility Resident Rights policy dated 7/23, reviewed 11/1/23, indicated residents have the right to receive the services and items included in the resident's plan of care. Review of Resident R6's clinical record indicated he was admitted to the facility on [DATE]. Review of Resident R6's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 11/2/23, indicated diagnoses that included venous insufficiency (a condition when blood doesn ' t flow back properly to the heart,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records and staff interviews it was determined that the facility failed to ensure that a resident's drug regimen was free of unnecessary medication for one of two residents. (Resident R2) Findings include: Review of the facility policy Guidelines for Care giver Interaction with Dementia reviewed 11/3/23, indicated staff must interact with residents in a manner that supports dignity and enhances residents ' abilities to successfully participate in life. It was indicated staff must change their thinking from trying to control behavior to understanding and changing the reasons behind the behavior and recognize that the resident cannot always control his/her behavior. It was also indicated staff do not ridicule, scold, or use threatening tone of voice. Review of the facility policy Right of Refusal reviewed 11/1/23, indicated the resident has the right to refuse treatment. It was indicated the team will assess the resident ' s needs and offer the resident alternative…

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, review of clinical records, facility policies and documentation, and staff interviews, it was determined that the facility failed to maintain an effective infection prevention and control program by failing to follow infection control guidelines from the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections. This failure resulted in seven of ten residents not positive for COVID-19 remaining in room with a resident with a COVID-19 positive resident (Residents R2, R4, R6, R8, R10, R12, and R14) and two of seven residents who remained in a room with a COVID-19 positive resident becoming positiveand symptomatic of COVID-19 (Residents R2 and R4). Findings include: Pennsylvania Health Alert Network (PA-HAN) - 694, Interim Infection Prevention and Control Recommendations for COVID-19 (a contagious viral disease that can cause a variety of symptoms, including breathing problems, fever, and cough) in Healthcare Settings dated 5/11/23, indicated Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door…

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 financial documents, interviews with vendors and staff, it was determined that the facility failed to pay bills in a timely manner for services without which the residents' health and safety are potentially impacted. Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), dated July 1, 2023, indicated that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are jeopardized. Review of facility provided Accounts Payable Ledger 1 on 9/13/23, at 11:53 a.m. indicated Nursing Staffing Agency 1 with an outstanding balance of $9,195.30 for services from 6/7/23 -8/2/23. Interview with Nursing Home Administrator on 9/13/23, at 1:00 p.m. indicated that they solely used Nursing Staffing Agency 2 as their primary vendor for nursing staff vacancies for the past three months or so and that Nursing Staffing Agency 1 didn't send them anybody. Review of facility provided…

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

Based on review of facility policy, personnel files and staff interviews it was determined that the facility failed to complete annual performance evaluations for three out of eight personnel files (Nurse Aide Employee E5, Nurse Aide Employee E6, and Nurse Aide Employee E7). Findings include: The facility Annual nurse aide evaluation document (no date), indicated that the evaluation is meant to judge performance at work and to help improve skills and techniques. Review of Nurse aide Employee E5's personnel record indicated she was hired on 10/7/13. Review of Nurse aide Employee E5's personnel record did not include an annual performance evaluation for the year 2022. Review of Nurse aide Employee E6 personnel record indicated he was hired on 6/20/16. Review of Nurse aide Employee E6's personnel record did not include an annual performance evaluation for the year 2022. Review of Nurse aide Employee E7 personnel record indicated she was hired on 2/24/99. Review of Nurse aide Employee E7's personnel record did not include an annual performance evaluation for the year 2022. During an…

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

Based on review of facility documentation and staff interview it was determined that the facility failed to employ qualified staff to oversee the kitchen for six out of 12 months (January of 2023 to June of 2023). Findings include: Review of job description indicated that dietary manager indicated: Be a graduate of an accredited course in dieticians training approved by the American Dietetic Association. During an interview on 6/7/23, at 2:13 p.m. Food Service Director Employee E11 indicated that he did not have the required certification for the Food Service Director job. During an interview on 6/8/23, at 10:50 a.m. Corporate Consultant RD (Registered Dietitian) Employee E12 and they are not they do not supervise the dietary manager for certification course work. The facility provided documentation for dietary manager certification course work dated 6/5/23, but could not provide any other documentation. During an interview on 6/8/23, at 10:55 a.m. Corporate Consultant RD Employee E12 confirmed that the facility failed to have a dietary manager who has current certification from 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 facility policy, resident clinical record, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of neglect for one out of three sampled resident records (Resident R30). Findings include: The Abuse reporting policy dated 8/2016, and last reviewed 1/23/23, indicated that the facility will thoroughly investigate all reports of suspected or alleged abuse, neglect or exploitation. Injuries of unknown origin will be investigated to rule out potential abuse. The facility shall notify the Department of Health in compliance with Federal and State regulation. The Pennsylvania Department of Health will be notified of the alleged event via the electronic reporting system. Review of Resident R30's admission record indicated she was admitted on [DATE]. Review of Resident R30's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) 3/18/23, indicated she was admitted with diagnoses…

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, clinical record review, staff interview it was determined that the facility failed to implement a care plan for assistance with eating for one of four residents (Resident R1). Findings include: Review of facility policy MDS/RAI/Care Planning dated 3/12/23, indicated: Develop a written plan of care individualized for each resident , which identifies through an assessment process his/her strengths, problems and needs. Review of Resident R1 clinical record was admitted [DATE], with the following diagnosis of dystonia ( a state of abnormal muscle tone, resulting in muscular spasm and abnormal posture) and aphasia (a disorder that affects how you communicate). These diagnosis remained current as of the MDS (minimum data set a periodic assessment of resident needs ) dated 12/1/23. Review of incident Choking dated 12/15/23, indicated that Resident R1 was heard coughing, NA (Nurse Aide) Employee E10 went in and Resident R1 indicated that he was choking. NA Employee E10 went and got 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 review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as per order for one out of three residents (Resident R37). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record and staff interview it was determined that the facility failed to provide a diagnosis for a psychotropic medication for one of five Residents (Resident R54). Findings include: Review of facility policy Antipsychotic Drugs dated 1/23/23, indicated: Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. Review of Resident R54 clinical record indicated admission on [DATE], with the diagnosis of major depressive disorder recurrent (type of clinical depression - persistently depressed mood). Additional review of Resident R54 clinical record - physician orders dated 5/1/23, indicated: Abilify Maintena Intramuscular Prefilled Syringe 300 MG - Inject 300mg intramuscularly one time a day starting on the 1st and ending on the 1st every month related to schizophrenia and bipolar disorder. Review of the clinical record…

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.