Embassy Of Hillsdale Park

Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 33 residents reviewed (Resident 54). Findings include: The facility's policy for abuse, dated November 8, 2024, indicated that the facility will not tolerate abuse, neglect, and exploitation of its residents or the misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated February 11, 2025, revealed that the resident was rarely understood, could rarely understand, and had diagnoses that included Alzheimer's disease and Down's syndrome. A care plan for Resident 54, dated…

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

Based on a review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide a reasonable accommodation of needs by failing to ensure that the call bell was within reach for one of 33 residents reviewed (Resident 27). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated December 13, 2024, indicated that the resident was cognitively impaired and required maximum assistance for transfers and toileting. The resident's current care plan indicated that the resident had recent falls, and staff were to ensure the call bell was within reach. The facility's call bell policy, dated November 8, 2024, indicated that the call bell would be within easy reach and secured if needed. Observations of Resident 27 on March 3, 2025, at 10:38 a.m. revealed that the resident was sitting in his wheelchair in the middle of his room with his call bell lying on his bed out of the resident's reach. Interview with Resident 27 at that time…

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 policies, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for one of 33 residents reviewed (Resident 74). Findings include: A facility policy for baseline care plans, dated November 8, 2024, indicated that the facility will develop a baseline care plan within 48 hours of a resident's admission that includes the minimum healthcare information necessary to properly care for a resident including, but not limited to, initial goals based on admission orders and physician's orders. Interventions shall be initiated that address the resident's current needs including any special needs such as for intravenous therapy (administration of fluids and/or medications directly into a person's vein). A nursing note for Resident 74, dated February 25, 2025, at 4:23 p.m., revealed that the resident was admitted to the facility on [DATE], with…

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

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of 33 residents reviewed (Resident 29). Findings include: The facility's policy for Comprehensive Care Plans, dated November 8, 2024, indicated that the facility develops and implements a comprehensive, person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. The comprehensive person-centered care plan is developed within seven days of the completion of the required comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. A significant change Minimum Data Set (MDS) assessment (a mandated…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 33 residents reviewed (Residents 9, 31). Findings include: The facility's policy for Comprehensive Care Plans, dated November 8, 2024, indicated that the facility develops and implements a comprehensive, person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. The comprehensive person-centered care plan is developed within seven days of the completion of the required comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident'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 clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician's orders regarding wound treatments were followed for one of 33 residents reviewed (Resident 74). Findings include: A nursing note for Resident 74, dated February 25, 2025, at 4:23 p.m. revealed that the resident was admitted to the facility on [DATE], with diagnoses that included a diabetic foot ulcer (a wound to the foot due to a complication of diabetes) and peripheral vascular disease (a disease causing poor blood circulation to lower limbs). Physician's orders for Resident 74, dated March 1, 2025, included orders to cleanse the resident's right lateral diabetic foot ulcer with normal saline (a sterile solution used for the moistening of wound dressings and wound debridement), apply betadine (a solution used to treat and prevent infection) to the base of the wound, and secure with abdominal dressing (used for a wound with large amounts of drainage or used 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.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide proper positioning in a wheelchair for one of 33 residents reviewed (Resident 38). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated November 29, 2024, revealed that the resident was cognitively impaired, required assistance with daily care needs, and had diagnoses that included Alzheimer's dementia and depression. Physician's orders for the resident, dated September 17, 2024, included orders for the resident to be seated in a Broda chair (modified wheelchair) at all times when out of bed with bolsters bilaterally to trunk, skil-care back pillow, and leg rests on during transport and off after transport. Observations on March 3, 2025, at 10:19 a.m. revealed that Resident 38 was sitting in a Broda chair in the activity room, and she was leaning to the right side with her head lying on the armrest. Observations on March 6, 2025, at 10:40 a.m. revealed that 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.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the environment remained as free of accident hazards as possible for one of 33 residents reviewed (Resident 14). Findings include: A facility policy for resident alarms, dated November 8, 2024, indicated that the use of alarms does not eliminate the need for adequate supervision of the resident. Wander/elopement alarms alert staff when the resident nears or exits an area or building. When alarms are utilized, additional monitoring shall be provided, including but not limited to verifying alarms are used in accordance with the resident's care plan and verifying alarms are working properly. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated November 10, 2024, indicated that the resident was cognitively impaired, required assistance with care needs, and had diagnoses that included Alzheimer's dementia. A care plan for the resident, dated March 11, 2024, revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to flush a PICC line (a tube placed in a vein that can be used to deliver fluids and/or medications) as ordered by the physician for one of 33 residents reviewed (Resident 74). Findings include: A nursing note for Resident 74, dated February 25, 2025, at 4:23 p.m. revealed that the resident was admitted to the facility on [DATE], with diagnoses that included a diabetic foot ulcer (a wound to the foot due to a complication of diabetes) and peripheral vascular disease (a disease causing poor blood circulation to lower limbs). She had a peripherally inserted central catheter (PICC - a thin tube inserted into a vein and used long term for the administration of fluids and/or medications) in her right upper arm for maintenance at that time. Physician's orders for Resident 74, dated February 25, 2025, included orders for the staff to maintain the resident's PICC and flush each port every 12…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for one of 33 residents reviewed (Resident 46). Findings include: The facility's policy regarding medication administration, dated November 8, 2024, indicated that staff were to document that medication was given on the appropriate line of the resident's Medication Administration Record (MAR). Physician's orders for Resident 46, dated November 20, 2023, included an order for the resident to receive a 1 milligram (mg) tablet of Ativan (an anti-anxiety medication) every six hours as needed. Resident 46's controlled drug records for January and February 2025 revealed that a 1 mg dose of Ativan was signed-out on January 21, 2025, at 7:50 a.m. and February 28 2025, at 8:00 a.m.; however, the resident's clinical record, including the MAR, contained no documented evidence that the Ativan was actually administered to the resident. Interview with the…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of as needed anti-anxiety medications for one of 33 residents reviewed (Resident 46). Findings include: A quarterly Minimum Date Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated February 1, 2025, indicated that the resident was cognitively impaired, was understood and was able to be understood by others, and had physical behaviors directed toward others. The resident's care plan dated January 14, 2024, revealed that staff were to minimize the potential for disruptive behaviors by offering tasks that divert attention. Physician's orders, dated February 4, 2025, and February 19, 2025, included an order for the resident to receive 1 milligram (mg) of Ativan (an anti-anxiety medication) every six hours as needed for agitation. Resident 46's Medication Administration Record (MAR) for February 2025 and March 2025…

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

Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending April 11, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending March 6, 2025, identified repeated deficiencies related to abuse and neglect, updating/revising care plans, quality of care, and a safe environment that is free of accident hazards. The facility's plan of correction for a deficiency regarding failure to ensure residents were free from abuse and neglect, cited during the survey ending April 11, 2024, revealed that the…

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

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for blood sugar checks were obtained by a professional (registered) nurse for one of 33 residents reviewed (Resident 24). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. Physician's orders for Resident 24, dated October 4, 2024, included an order for the resident to receive one 500 milligram (mg) tablet of Metformin (helps to control the amount of glucose (sugar) in your blood) in the morning at 7:00 a.m. Resident 24's Medication Administration Record (MAR), dated March and April 2024, revealed that…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice by failing to ensure that physician's orders were followed for four of 33 residents reviewed (Residents 12, 14, 22, 24). Findings include: The facility's policy regarding medication administration, dated March 14, 2024, indicated that staff were to obtain and record vital signs when applicable or per physician's orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. An annual Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 12, dated February 22, 2024, revealed that the resident was understood and could understand others, was cognitively intact, and required minimal assistance with care. A nursing note for Resident 12, dated March 16, 2024, revealed that the nurse aide noticed that the resident's left eye was red and…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for two of 33 residents reviewed (Residents 3, 30). Findings include: The facility's policy regarding pressure ulcers, dated March 14, 2024, indicated that the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 3, dated March 29, 2024, indicated that she was cognitively intact, had no history of rejecting care, required extensive assistance from staff for daily care needs, and had an unhealed Stage 3 pressure ulcer. A physician's progress note, dated March 29, 2024, revealed that Resident 3 was to be assessed for an air mattress to assist with pressure distribution. Observations…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards caused by residents with aggressive behaviors for four of 33 residents reviewed (Residents 44, 58, 61, 63). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated December 15, 2023, revealed that she was understood, could understand, and had a diagnosis of dementia. A care plan for the resident, dated September 8, 2023, revealed that the resident had an alteration in behavior related to abusive attacks on staff and/or other residents; verbally abusive, threatening behaviors; argumentative with staff; yells at staff and other residents, and a history of resident-to-resident altercations. Staff were to intervene as needed to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation…

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

Based on review of policies and clinical records, medication manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled/dated for three of 33 residents reviewed (Residents 10, 11, 45). Findings include: The facility's policy for labeling medications, dated March 14, 2024, indicated that all pre-filled pens and multi-dose vials of medication maintained in the facility shall be labeled with date opened and the initials of the healthcare professional, and are to be discarded within 28 days unless otherwise specified by the manufacturer. The most current manufacturer's instructions for insulin Humalog Kwikpen Pen-injector 100 unit/ml (milliliter) solution (a fast acting insulin) indicated that prefilled pens that are in use should be kept at room temperature and must be used within 28 days or be discarded. Physician's orders for Resident 10, dated July 9, 2023, included an order for Keppra solution (medication used to treat seizures) 100 mg/mL 5 ml by mouth two times a day.…

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

Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 33 residents reviewed (Resident 58). Findings include: The facility's policy for abuse, dated March 14, 2024, indicated that the facility will not tolerate abuse, neglect, and exploitation of its residents or the misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 117, dated June 8, 2023, revealed that the resident was usually understood, could usually understand, and had diagnoses that included dementia and schizophrenia (a serious mental illness that…

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

Based on review of facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to review and revise care plans for three of 33 residents reviewed (Residents 1, 3, 51). Findings include: The facility's policy regarding care plans, dated March 14, 2024, indicated that the care plan revisions would be reviewed, and revised as necessary, when a resident experiences a status change. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 19, 2024, indicated that the resident was moderately cognitively impaired and was not receiving an anticoagulant (blood thinner) medication. Resident 1's care plan, dated February 2, 2024, indicated that the resident had the potential for bleeding or hemorrhage related to the use of anti-coagulant medication. A review of Resident 1's physician's orders and Medication Administration Record (MAR) for April 2024 revealed that the resident was not receiving an anticoagulant medication. Resident 1'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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide appropriate care to prevent urinary tract infections for one of 33 residents reviewed (Resident 1) who had an indwelling urinary catheter. Findings include: The facility's policy regarding indwelling urinary catheters (a flexible tube inserted and held in the bladder to drain urine), dated March 14, 2024, revealed that care would be taken to follow infection control guidelines when providing catheter care and emptying the drainage bag. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 19, 2024, revealed that the resident was moderately cognitively impaired, required assistance from staff for daily care activities, had an indwelling urinary catheter, and had diagnoses that included neurogenic bladder (lack of bladder control). Physician's orders, dated December 28, 2023, included an order for the resident to have a urinary catheter, 18…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 33 residents reviewed (Resident 22). Findings include: The facility's policy regarding medication administration, dated March 14, 2024, indicated that the facility was to administer medication in accordance with the physician orders. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated March 14, 2024, revealed that the resident had diagnoses that included diabetes (a disease that interferes with blood sugar control) and received insulin. Physician's orders for Resident 22, dated December 15, 2022, included an order for the resident to receive 6 units of Lispro insulin subcutaneously (injected just under the skin) one time a day in the morning, 6 units one time a day at the lunch meal, and 6 units one time a day at the supper meal, and to hold the insulin if the resident's blood sugar was less than or…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to obtain a physician's order for an invasive procedure to collect a specimen for a laboratory test for one of 33 residents reviewed (Resident 24). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated January 10, 2024, revealed that the resident was understood and understands. Physician's orders, dated January 4, 2024, included an order to obtain a urine culture (a test that looks for and identifies bacteria in urine) and sensitivity (a test that helps find out which antibiotic will be most effective in treating a bacterial infection). A progress note for Resident 24, dated January 5, 2024, revealed that the resident was straight cathed (an invasive procedure in which a plastic tube is inserted into the bladder) for a dark amber urine and the sample was sent to the lab. There was no documented evidence that staff obtained a physician's order to obtain Resident 24's urine…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plan of correction for the State Survey and Certification (Department of Health) survey ending May 11, 2023, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending April 11, 2024, identified repeated deficiencies related to the revision of care plans, failure to ensure that residents remained free of significant medication errors, and medication storage and labeling. The facility's plan of correction for a deficiency regarding revising care plans, cited during the survey ending May 11, 2023, revealed that…

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

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of five residents reviewed (Resident 3). Findings include: A facility policy for resident showers dated March 14, 2024, indicated that residents will be provided showers as per request or as per facility schedule protocols. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 21, 2024, indicated that the resident was cognitively impaired, was dependent on staff for showers and bathing, and had diagnoses that included peripheral vascular disease. A care plan for Resident 3, dated December 12, 2023, indicated that the resident required two staff members to provide care. A care plan, dated January 1, 2024, indicated that the resident was to be assisted with showering as per facility policy weekly. A review of the facility shower schedule indicated that Resident 3 was to have a shower every…

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.