Quadrangle

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and the review of clinical records, it was determined that the facility failed to ensure that podiatrist services were provided for 1 out of 17 residents reviewed (Resident R47). Findings include: Review of the resident's Inpatient Discharge Summary dated 2/6/2025, indicated that the resident was admitted to the hospital on [DATE] after having a fall at home. The resident was transferred to the facility on February 6, 2025 for rehabilitation services. Review of the April 2025 physician orders for Resident R47 included the following diagnoses of diabetes (a condition characterized by elevated levels of blood glucose ,and a condition that makes an individual with the diagnosis at greater risks for developing foot problems ); hypertension (high blood pressure); hyperlipidemia (high cholesterol). During an interview with Resident R47 on April 2, 2024 at 11:30 a.m., Resident R47 reported that she had been at the facility since February 2025, had diabetes, had requested on a number 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 interviews with staff, it was determined that the facility failed to obtain orders for urinary catheter for one of two clinical records of residents with urinary catheters reviewed (Resident R46). Findings include: Review of Resident R46's clinical record revealed that resident was admitted to the facility on [DATE], with diagnoses of but not limited to Chronic Urinary Tract Infection, Chronic Tubulo-interstitial Nephritis, Benign Prostatic Hypertrophy with Lower Unitary Tract Symptoms, Bladder Neck Obstructions and Uro-genital Implant Further review of Resident R46's clinical record revealed that Resident R46 was discharged to the hospital on March 25, 2025, and was re-admitted to the facility on [DATE]. Review of Resident R46's clinical record (service evaluation and health assessment) dated March 29, 2025, revealed that resident R46 was admitted s/p (status post) pyelonephritis recurrent UTI (urinary track infection), has foley- (indewelling urinary catheter) intact 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 observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that intravenous (IV) devices were maintained in accordance with professional standards of practice for one of one residents reviewed for intravenous therapy (Resident R106). Findings include: Review of facility policy, Vascular Access Devices and Infusion Therapy Procedure, Peripherally Inserted Central Line Catheter (PICC)[ a thin soft tube inserted in a vein in the arm with the tip of the tube positioned in a large vein that carries blood to the heart] dated October 2024, revealed, Measure circumference of upper arm before insertion or on admission as a baseline and when clinically indicated to assess for the presence of edema [excess fluid] and possible deep vein thrombosis [blood clot]. Measure 10 c.m. [centimeters] above the insertion site. Measure external length of PICC catheter at insertion or on admission, with each dressing change,…

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 interviews with staff, it was determined that the facility failed to obtain orders for oxygen for one of 17 clinical records reviewed (Resident R21). Findings include: Review of Resident R21's clinical record revealed that Resident R21 was admitted to the facility on [DATE], with diagnoses of Chronic Respiratory failure with Hypoxia (low levels of oxygen). Further review of Resident R21's clinical record revealed a care plan for oxygen therapy related to chronic heart failure date initiated: 03/11/2025. Further review of Resident R21's clinical record revealed that there was no physician's orders for oxygen. Review of Resident R21's Daily Skilled Evaluation dated March 26, 2025 revealed that under section Skilled Services, 7a, #1:Oxygen was coded yes and 7c. Respiratory management: document evaluation and response to above selected services (may include respiratory pattern changes, lung sounds, O2 sat monitoring, endurance levels, shortness of breath upon exertion, shortness…

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 clinical records, facility documentation, and interviews with residents and staff, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care of residents with intravenous (IV) devices for two of five employees reviewed for IV skills competencies (Employees E15 and E16). Findings include: Observation on March 31, 2025, at 12:42 p.m. revealed that Resident R106 had a PICC (intravenous) line in his right upper arm. Resident R106 stated that he received antibiotic medication through the PICC line twice per day. Review of Resident R106's care plan revealed that the resident was admitted to the facility on [DATE], to receive intravenous antibiotic therapy due to sepsis (infection in the blood). Review of Resident R106's physician orders revealed an order, dated March 25, 2025, to administer cefazolin (antibiotic mediation) intravenously every 12 hours for bloodstream infection. Continued 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 observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for two of three medication carts reviewed (Second floor nursing unit A and C medication carts). Findings include: Review of facility policy, Narcotic Reconciliation dated revised July 11, 2022, revealed, Controlled medications are counted at the beginning and end of each shift by two authorized team members at the same time. The incoming authorized team member counts the controlled medication. The outgoing authorized team member visually verifies the actual number of controlled medications regardless of form against the amounts listed on the declining inventory sheets. The number of unit-dose/blister pack medication cards is also verified during the drug count process. This process is done together for each controlled medication to be reconciled. Observation on April 1, 2025, at 9:08 a.m. of the second floor nursing unit A medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and procedure, staff interview and review of clinical record, it was determined that the facility failed to maintain an effective infection control program related to contact precaution and maintenance of urinary catheter/urine bag for two of 17 residents observed. (Resident R46 and Resident R159) Findings include: Review of facility policy on Transmission Based Precaution revealed that transmission-based precautions are used for residents with documented or suspected infection or colonization with highly transmissible pathogens. Communicate the type of precautions required though verbal reports, hand-off reports, entering on the alert page in [Eletronic System] and posting signs outside the resident's rooms. Contact Precautions for resident with known or suspected infections that are of an increased risk of being transmitted by direct contact with the resident or the resident's environment. Use the following guidelines to manage the care of residents on contact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, review of select manufacture's guidelines, and staff interview, it was determined that the facility failed to ensure a medication error rate of less than 5 percent for 1 out of 2 residents reviewed. (Resident R3). Findings include: The facility's policy title Medication Administration General Guidelines revised 2027 states Medications are administered as prescribed in accordance with manufactures' specification, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The facility's New admission Checklist policy unknown creation date, reveals Prior to admission, enter allergies into system, put in ancillary orders see separate sheet/documents; save in queue, pt (patient) in medication order save in queue, add diet order in queue, add code status, verify orders with assigned doctor/NP (nurse practitioner). Review of…

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

Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: Review of facility policy titled, Food Storage, Preparation and Service revised April 11, 2022, revealed that cutting boards are color coded and used according to food type. The red cutting board is to be utilized for raw meat and processed (not raw) items are to be handled on a white cutting board. Further review revealed that all food items are labeled, dated and rotated to maintain a system of First In First Out (FIFO). An initial tour of the Food Service Department was conducted on May 20, 2024, at 10:14 a.m. with the Food Service Director (FSD), Employee E5, and the Dietary Manager (DM), Employee E6. Observations revealed the following: Employee E11, the Cook, was observed cutting vegetables on the white cutting board. Further observation revealed Employee E11 proceeded to handle raw ground…

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

Based on observations and interviews with staff, it was determined that the facility failed to ensure that garbage was dispose of properly. Findings include: Observation in the receiving area revealed five dumpsters with the lid open revealing contents; dirty plastics were observed around the dumpsters. The ground all around the loading dock was littered with hundreds of cigarette butts. Interview with Food Service Director at 9:45 a.m. on May 14, 2024, 10:40 a.m. confirmed the above findings.

Based on review of clinical records, facility policies and procedures, interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation of one alleged violation of unknown source of injury for one of 16 residents reviewed. (Resident R165). Findings include: Review of the facility policy titled, Abuse, Neglect & Exploitation - Prevention, Reporting and Investigation dated, May 4, 2016, revealed, The SNA/designee manages and directs the investigation of all abuse, neglect and/or exploitation. Review of facility investigation dated August 21, 2023, revealed that while providing care, a nurse aide transferred Resident R165, and her head hit the guard rail. This resulted in a hematoma on the right side of her forehead. Resident was sent to the hospital for further assessment. Further review of the investigation revealed a statement by Employee E13, nurse aide revealed that she provided care to resident including transfer with the help of other staff. She also provided care to resident in bed. Employee E13 indicated that there was 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.

Based on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer to the hospital in a timely manner, in writing and in a language and manner they understoodfor one of 16 residents reviewed. (Resident R52) Findings Include: Review of nursing note for Resident R52, dated May 8, 2024, revealed that the resident was febrile (having or showing symptoms of a fever), and was discharged to the hospital. Further review revealed a nursing note for Resident R52, dated April 26, 2024, revealed that the resident was discharged to the hospital for systemic anemia. Another nursing note for Resident R52, dated March 11, 2024, revealed that the resident was admitted to the hospital with acute kidney injury. Review of clinical record revealed no evidence that Resident R52's representative was notified of the transfer to the hospital and the reasons for the transfer in writing, and in a language and manner they understood. Interview…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for one of 16 residents reviewed. (Resident R52) Findings include: Review of nursing note for Resident R52, dated May 8, 2024, revealed that the resident was febrile (having or showing symptoms of a fever), and was discharged to the hospital. Further review revealed a nursing note for Resident R52, dated April 26, 2024, revealed that the resident was discharged to the hospital for systemic anemia. Another nursing note for Resident R52, dated March 11, 2024, revealed that the resident was admitted to the hospital with acute kidney injury. Further review of Resident R52's clinical record revealed that there was no documented evidence that the resident and his representative were provided with a written notice of the facility bed-hold policy at the time of Resident R52's facility-initiated transfer to the hospital. Interview…

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, review of clinical records, and staff interview, it was determined that the facility failed to monitor and modify interventions consistent with the resident's needs to maintain acceptable parameters of nutritional status for two of three residents reviewed for nutritional status (Resident R44 and R55). Findings Include: Review of facility policy titled, Nutritional Intervention Pathways for Weight Loss undated, revealed that oral supplements must be obtained from the physician and documented. Review of facility policy titled, Fortified Foods revised June 7, 2016, revealed that fortified foods will meet the increased nutritional needs of residents who are underweight, have significant weight loss, pressure ulcers or poor intake. Once the physician approves the fortified food, a diet order written as Fortified food will appear in the resident's medical records. Recipes, amount to be served and frequency must be kept on file. Further review revealed that acceptance 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.

Based on the review of clinical records, facility documentation, observations, interview with staff, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care of residents with intravenous line and medication administration for two of two employee records reviewed. (Employee E14 and E15). Findings Include: Review of facility reported incident dated December 14, 2024, revealed that Resident R164 was involved in a medication error. Nurse accidentally administered Sertraline (Antidepressant) 100 milligrams (mg) tablet and Lisinopril (Blood Pressure medication) 10 mg. Resident's family requested evaluation from nurse practitioner in-house. They were not available and therefore resident was sent to the hospital for further evaluation. Review of clinical record revealed that the medication was administered by Licensed nurse, Employee E15. A request for medication administration competency prior to the medication error was requested to the Director of Nursing n May 21, 2024. Facility did not provide…

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

Based on review of the clinical records, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that a resident was free of significant medication error for two of five residents reviewed for medication administration (Resident R164 and Resident R167). Findings include: Review of facility reported incident dated December 14, 2024, revealed that Resident R164 was involved in a medication error. Nurse accidentally administered sertraline (Antidepressant) 100 mg tablet and lisinopril (Blood Pressure medication) 10 milligrams (mg). Resident's family requested evaluation from nurse practitioner in-house. They were not available and therefore resident was sent to the hospital for further evaluation. Review of physician orders for Resident R164 on December 14, 2023, revealed that there was no physician orders for sertraline and lisinopril. Interview with Director of Nursing on May 21, 2024, stated nurse did not follow appropriate practice of medication administration. The nurse who administered medication to Resident R64 was unable to…

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

Based on review of facility documents and staff interviews, it was determined that the facility failed to ensure that the Medical Director or designee was in attendance at monthly Quality Assurance Process Improvement (QAPI) Committee meetings for three of three months reviewed. (January 2024 through April 2024) Findings include: A review of QAPI Committee meeting sign-in sheets for the period of January 2024 through April 2024, revealed no documented evidence that the Medical Director or other physician was in attendance, virtually or in-person, at the QA meetings held from January 2024 through April 2024. Interview with the administrator on May 22, 2024, at 12:00 PM confirmed that the facility documentation did not show evidence that the medical director was in attendance, virtually or in-person, at the QA meetings held from January 2024 through April 2024. 28 Pa. Code 211.2(d)(5)(6)(7)(8)(10) Medical director 28 Pa. Code 201.18 (e)(2)(3)(4) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of clinical records and the review of facility documentation, it was determined that the facility failed to ensure that a complete and through investigation was completed to rule out neglect for a bruise of unknown origin for 1 out of 14 residents reviewed (Resident R35). Findings include: Review of the facility's policy, Abuse, Neglect & Exploitation, undated, revealed Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The SNA/designee manages and directs the investigation of all abuse, neglect and/or exploitation. Interview with facility Administrator on August 7, 2023, at approximately 10:17 a.m. failed to provide a policy or investigation procedure regarding injury of unknown origin. Review of Resident R35's Quarterly Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) indicated that the resident was admitted to the facility on [DATE], with diagnoses including dementia (the loss 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans for hearing difficulty and scratching behaviors for two of 21 residents reviewed (Resident R8 and R35). Findings include: A review of the facility policy titled, Individualized Care Plan, revised October 20, 2022, revealed, the IDT develops comprehensive care plan addressing the residents most acute problems. The comprehensive care plan will include services that are to be furnished to attan or maintain the residents highest practicable physical, mental and psychological well-being. During resident screening conducted on August 2, 2023, on the second floor, at approximately 12:28 p.m. revealed Resident R8 sitting in her room at bedside. Surveyor greeted Resident R8 at the door but Resident R8 did not look up. After several greeting attempts, each attempt louder than the previous, resident still had not acknowledged surveyor due to hard of hearing. A review of 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 a review of the clinical record and staff interview, it was determined that the facility failed to ensure that a complete discharge summary was completed for two of three closed records reviewed (Resident R154 and R48). Findings Include: Review of Resident R154's clinical record revealed the resident was discharged to the hospital on [DATE], and did not return to the facility after hospitalization. Review of Resident R48's clinical record revealed the resident expired at the facility on [DATE]. Further review of the clinical records revealed no documented evidence that the physician completed a discharge summary with a recapitulation of the resident's stay at the facility. Interview on [DATE], at 1:50 p.m. with Employee E1, Nursing Home Administrator, confirmed discharge summaries were not available for Resident R154 and R48. 28 Pa. Code 211.5 (d) Medical Records 28 Pa. Code 211.5 (f) (xii) Medical Records

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews with staff, it was determined that the facility failed to obtain physician orders for one of 14 records reviewed for monitoring of a medication. (Resident R39). Finding include: Review of Resident R39's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated April 4, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including hypertension (high blood pressure) and congestive heart failure (heart is not able to pump blood efficiently so blood and fluids collect in your lungs and legs over time) and atrial fibrillation (irregular heart beat because blood not flowing proper in heart causing an increase in blood clot and increase of stroke). Review of Resident R39's physician orders instructed to obtain daily weights dated April 1, 2023 and Digoxin Oral Tablet 250 mcg, give 0.5 tablet by mouth one time a day related to atrial fibrillation. On April 3, 2023 the order changed to Digoxin oral tablet,…

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, review of clinical records, resident and staff interviews, it was determined that the facility failed to monitor hydration and nutritional supplement consumption for two of three residents reviewed for nutritional status. (Resident R22, and Resident R39) Findings include: Review of facility policy Nutrition and Weight Management Program in the section titled, Oral supplements, revealed Oral nutritional supplements such as Ensure and Boost are used as an intervention for nutritional supplementation. Staff is to monitor the resident's intake of supplements. Review of Resident R22's Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated June 8, 2023, revealed that the resident was admitted to the facility on [DATE], with diagnoses including Alzheimer's Dementia (a disease that destroys memory and other important mental functions). A review of Resident R22's BIMS (Brief Interview of Mental Status) revealed a score of ten,…

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, staff interview, review of resident records and facility policy, it was determined that the facility did not ensure one resident receiving respiratory care was provided care consistent with professional standards of practice for one of two residents reviewed receiving respiratory services (Resident R25). Findings include: Facility policy titled Oxygen Administration not dated stated, Oxygen is administered to residents who need it consistent with professional standards of practice. Review of Resident R25's clinicakl record revealed that the resident was admitted to the facility on [DATE], with the diagnosis of acute respiratory failure and used supplemental oxygen to assist in breathing. Physician orders dated May 2, 2023, instructed to Wean oxygen to keep SATS (oxygen saturation) above 90%. On August 2, 2023, at 11:29 a.m. with Licensed Nurse, Employee E5, Resident R25 was observed on 3 liters (L) of oxygen at bedside. Employee E5 stated she didn't know why it was on 3 L of oxygen, It'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.

Based on review of facility documentation, clinical records review, and staff interview, it was determined the facility failed to ensure an as needed psychotropic medication had documented rationale for continued use past 14 with a duration for the PRN order, failed to appropriately monitor the effects of the medication, and failed to administer the medication in accordance with prescriber recommendations for one of five residents reviewed for medication regimen reviews (Resident R28). Findings Include: Review of Resident R28's Quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 29, 2023, revealed the resident had a diagnosis of anxiety disorder (intense, excessive, and persistent worry and fear) and received antianxiety medications during the last seven days. Review of Resident R28's comprehensive care plan dated December 28, 2022, revealed the resident used anti-anxiety medications related to anxiety disorder. Interventions included to monitor/document/report any adverse reactions to anti-anxiety therapy. Review of Resident R28'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.

Based on review of facility documentation and staff interview it was determined that the facility failed to complete an annual review of the facility assessment for any potential resources needed. Findings Include: On August 2, 2023, at approximately 9:45 a.m. during an entrance conference meeting with Employee E1, Nursing Home Administrator, and Employee E2, Director of Nursing, surveyor requested a copy of the facility assessment within four hours per the entrance conference guidelines. A copy of the facility assessment was requested by surveyor again on August 2, 2023, at approximately 2:00 p.m. and on August 3, 2023, at 10:10 a.m. Review of facility assessment provided by the facility on August 3, 2023, at approximately 2:00 p.m. revealed the facility completed an annual review of the facility assessment on August 3, 2023. Review of facility documentation revealed the last annual review of the facility assessment was completed June 7, 2022. Subsequently, the facility assessment was not reviewed for any potential resources neccesary in the last 14 months. Interview on August 7,…

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