Lutheran Home At Hollidaysburg

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to three of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete…

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 job description, facility documents and staff interviews, it was determined that the facility failed to provide Infection Control training to two of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each…

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

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide compliance and ethics training to two of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each…

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

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to conduct the minimum 12 hours of nurse aide (NA) training per year for one of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their…

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 job description, facility documents and staff interviews, it was determined that the facility failed to provide Behavioral Health training to three of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each…

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

Based on clinical record reviews and staff interviews, it was determined the facility failed to provide clearly documented reasons for facility-initiated transfers to the hospital to the resident and resident's representative in language and manner that could be easily understood for five of 25 residents reviewed (Residents 8, 18, 35, 42, 47). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated August 4, 2024, revealed that the resident was cognitively intact, was independent with personal hygiene care needs, and had diagnosis that included dementia. A nurse's note for Resident 8, dated January 17, 2024, revealed that the resident had a fall in her bathroom and complained of right hip pain. The physician was notified, and the resident was transferred to the emergency room for evaluation. There was no documented evidence that a written notice of Resident 8's transfer to the hospital was provided to the resident or her responsible party regarding the reason for the transfer. A review of…

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

Based on review of 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 two of 25 residents reviewed (Residents 15, 29). Findings include: The facility's policy regarding care plans, dated January 11, 2024, indicated that the care plan is to ensure care and treatment is planned and individualized to the person's served problems/needs, conditions, impairment, disability, and or disease. If a significant change occurs, the care plan is to be reviewed for accuracy and completeness and revised if necessary. If any team member identifies an interim change that does not meet the definition of a significant change, the care plan may be adjusted accordingly. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated July 10, 2024, indicated that the resident was understood and able to understand others, was dependent on staff for personal hygiene care, and had diagnoses that included hemiplegia (paralysis 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 observations and staff interviews, it was determined that the facility failed to provide adequate supervision and failed to ensure that the environment remained as free of accident hazards as possible for three of 25 residents reviewed (Residents 4, 29, 40). Findings include: A facility policy for elopement, dated January 11, 2024, indicated that an elopement is defined as when a resident leaves the facility, or enters an unsafe area, without any team member being aware that the resident has done so. An analysis of each elopement is to be completed by the health care center management team, identifying all possible reasons why safety and security measures were breached. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated August 9, 2024, indicated that the resident was moderately cognitively impaired, had a history of wandering, was independent with personal hygiene needs and ambulation, and had diagnoses that included dementia. 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 polices and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for two of 25 residents reviewed (Residents 42, 45). Findings include: A facility policy for medication administration, dated January 11, 2024, indicated that medications were to be poured, administered, and documented by the licensed team member with accountability for the specific medication cart. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated August 28, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnoses that included diabetes, and received insulin. Physician's orders for Resident 42, dated August 22, 2024, included an order for the resident to receive Humalog insulin (medication used to lower blood sugar) subcutaneously (beneath the skin) with meals based on a…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plan of corrections for an annual survey ending October 12, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending September 13, 2024, identified repeated deficiencies related to a failure to develop and implement comprehensive care plans, failure to revise care plans, failure to protect residents from accidents/hazards, failure to store medications securely,; and failure to ensure that resident's medical records were complete and accurate. The facility's plan of correction for a deficiency regarding…

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 resident and/or resident representative had an opportunity to develop an advance directive (instructions regarding the provision of health care when the resident is incapacitated) or assist in formulating an advance directive for three of 25 residents reviewed (Residents 22, 27, 35). Findings include: The facility policy regarding advance directives and life sustaining treatment preferences, dated January 11, 2024, indicated that upon admission, the persons served will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the persons served indicates that he or she has not established advance directives, the healthcare center staff will offer assistance in establishing advance directives. The persons served will be given the option to accept or decline the assistance, and care will not be contingent on either…

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

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was developed to reflect the resident's specific care needs for one of 25 residents reviewed (Resident 29). Findings: The facility's policy regarding care plans, dated January 11, 2024, indicated that the care plan is to ensure care and treatment is planned and individualized to the person's served problems/needs, conditions, impairment, disability, and or disease. If a significant change occurs, the care plan is to be reviewed for accuracy and completeness and revised if necessary. If any team member identifies an interim change that does not meet the definition of a significant change, the care plan may be adjusted accordingly. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated June 14, 2024, revealed that the resident was cognitively impaired, was sometimes understood and sometimes able to understand others, and required assistance with…

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

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that ambulation programs to maintain or improve physical abilities were provided as ordered and/or care planned for one of 25 residents reviewed (Resident 2). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated June 11, 2024, revealed that the resident was cognitively impaired, was usually understood and able to usually understand others, and required partial/moderate assistance to walk 10 feet, 50 feet and 150 feet. A care plan for Resident 2, initiated July 28, 2024, indicated that the resident had the potential for decline in abilities and was placed on an ambulation program. Staff was to offer assistance with the program as directed and was to incorporate programs into activities or tasks to improve participation (such as ambulate to/from bathroom and to/from dining room). The original initiation date for her restorative ambulation program was documented as August…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 25 residents reviewed (Resident 45). Findings include: A review of the clinical record for Resident 45 revealed that the resident was admitted to the facility on [DATE], with diagnoses that included diabetes. Physician's orders for Resident 45, dated September 8, 2024, included an order for the resident to have her blood sugar checked before meals and at bedtime and for staff to administer sliding scale (dose is based on a person's blood sugar) insulin (medication used to lower blood sugar). Review of the Medication Administration Record (MAR) for Resident 8, dated September 2024, revealed no documented evidence that the resident's blood sugar was checked to determine if insulin was required on September 9 before breakfast, on September 10 before breakfast, and on September 10 before supper. Interview with the Director of Nursing on September 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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for one of 25 residents reviewed (Resident 4). Findings include: The facility's policy regarding treatment/medication administration, dated January 11, 2024, indicated that medications are administered in a safe and timely manner, and as prescribed and recorded on the resident's treatment administration record (TAR). A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated June 29, 2024, revealed that the resident was cognitively impaired, was understood and able to understand others, required assistance with care needs, was dependent for transfers, had two unstageable pressure ulcers (full-thickness pressure injuries in which the base is obscured by slough and/or eschar), and had a diagnosis that included peripheral vascular disease (disease reducing blood flow to the legs). A care…

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

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that interventions were in place to prevent urinary tract infections for one of 25 residents reviewed (Resident 13) who had an indwelling urinary catheter. Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated August 8, 2024, revealed that the resident had diagnoses that included dementia and obstructive uropathy (when urine cannot drain through the urinary tract) and had an indwelling urinary catheter (a flexible tube inserted and held in the bladder to drain urine). Physician's orders for Resident 13, dated August 6, 2024, included an order for the resident to have an indwelling urinary catheter due to having an obstruction and urinary retention. A care plan, dated August 6, 2024, indicated that the catheter tubing and collection bag were to be kept off the floor. Observations of Resident 13 on September 12, 2024, at 12:31 p.m. and 12:37 p.m. revealed that she was in her…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that interventions to maintain nutrition were provided as recommended by the dietician for one of 25 residents reviewed (Resident 13). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated August 8, 2024, revealed that the resident was cognitively intact, required supervision with eating, weighed 106 pounds, and had weight loss. Dietary notes for Resident 13, dated August 26, 2024, at 3:41 p.m., revealed that the resident had a significant weight loss and the dietitian recommended to the physician to add four ounces of magic cup (frozen nutritional supplement) daily with dinner and four ounces of enriched pudding (pudding with additional nutrients) daily with lunch. Observations of Resident 13 during the lunch meal on September 12, 2024, at 12:31 p.m. revealed that the resident was sitting in her room eating her meal, and she did not have enriched pudding. The 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 a review of facility job descriptions and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that staff renewed the nurse aide registry to allow individuals to work as a nurse aide for one of six nurse aides reviewed (Nurse Aide 3). This deficiency was cited as past non-compliance. Findings include: The facility's job description for Nurse Aide, undated, revealed that a nurse aide certification was necessary to perform functions of the position. The personnel file for Nurse Aide 3 revealed that her certification on the nurse aide registry expired on [DATE]. The facility was unaware that Nurse Aide 3's certification on the nurse aide registry was expired until it was discovered it on [DATE]. Nurse Aide 3 worked in the facility from [DATE] to [DATE]. Interview with the Nursing Home Administrator on [DATE], at 1:21 p.m. confirmed that Nurse Aide 3's certification on the nurse aide registry expired on [DATE], and should have been renewed prior to expiring 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 ensure the accountability of controlled medications (drugs with the potential to be abused) for one of 25 residents reviewed (Resident 3). Findings include: A facility policy for medication administration, dated January 11, 2024, indicated that medications were to be poured, administered, and documented by the licensed team member with accountability for the specific medication cart. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 9, 2024, revealed that the resident was cognitively impaired, was understood and understands, had pain, and received an opioid (a controlled pain medication). Physician's orders for Resident 3, dated November 29, 2023, included and order for the resident to receive 5-325 milligrams (mg) of hydrocodone-acetaminophen three times a day for chronic arm pain. Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a…

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

Based on review of policies, observations, and staff interviews, it was determined that the facility failed to properly secure and store medications in one of two medication rooms (front hall). Findings include: The facility's policy regarding medication storage, dated January 11, 2024, indicated that all drugs and biologicals were to be stored in a safe, secure, and orderly manner. The nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals were to be locked when not in use. Unlocked medication carts were not to be left unattended. Observations on September 9, 2024, at 10:25 a.m. revealed that the door to the medication room on the second floor (front hall) was left open and unattended. The medication cart was stored inside the medication room and was unlocked. Interview with Licensed Practical Nurse 4 on September 9, 2024, at 10:28 a.m. confirmed that she was down the hallway…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that laboratory specimens were obtained as ordered by the physician for one of 25 residents reviewed (Resident 3). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 9, 2024, indicated that the resident was cognitively impaired and was receiving an anticoagulant (blood thinner). A care plan, dated January 20, 2023, indicated that the resident had a history of deep vein thrombosis (blood clot that develops in a deep vein) and pulmonary embolism (blood clot that goes to lung), and Coumadin was to be administered as ordered and laboratory results were to be monitored per physician orders. Physician's orders for Resident 3, dated August 28, 2024, included an order for the resident to receive 6.5 milligrams (mg) of Coumadin (a blood thinner) daily and to check the PT/INR (a test that indicates how much time it takes for the blood to clot) on September 4, 2024. A review of…

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

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that staff used proper infection control techniques during incontinent care for one of 25 residents reviewed (Resident 30). Findings include: The facility's policy regarding hand washing, dated January 11, 2024, indicated that hand washing is the single most important means of preventing infection, and that hands are to be washed after the care of the resident, and after any contact which may contaminate you. Gloves are worn when there is contact with blood and body fluids, secretions, and excretions. Gloves are not a substitute for hand washing, and hands are to be washed even when gloves are worn. A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 30, dated August 31, 2024, indicated that she was cognitively intact, was dependent on staff for toileting hygiene, had an indwelling catheter (a thin, hollow tube that is inserted into the bladder to collect 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, observations, and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for four of 24 residents reviewed (Residents 2, 30, 31, 38). Findings include: A facility policy for care planning, dated January 11, 2023, indicated that if any interdisciplinary team member identified an interim change, the care plan would be adjusted accordingly. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 11, 2023, revealed that the resident was cognitively impaired and required extensive assistance from staff for her daily care needs. The resident's care plan, most recently updated on July 11, 2023, revealed that the resident was at risk for falls due to her impaired cognition. Physician's orders for Resident 2, dated May 1, 2022, included an order for the resident to receive two fall mats for safety. Observations of Resident 2 on October 10, 2023, at 10:35 a.m.…

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

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary medications for one of 24 residents reviewed (Resident 26). Findings include: The facility's policy for Psychotropic Medication Use, dated January 11, 2023, indicated that residents receiving psychotropic (cause changes in mood and behavior) drugs will be monitored for targeted behaviors and side effects. Behavioral approaches are to be utilized prior to giving as needed medications. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 26, dated August 15, 2023, revealed that the resident was understood and able to understand others, required extensive assistance with daily care needs, and had diagnosis that included Alzheimer's disease. Physician's orders for Resident 26, dated August 23, 2023, included an order for the resident to receive 0.25 milligrams (mg) of alprazolam (a psychotropic medication to treat anxiety) every six hours…

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, manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to label multi-dose containers of insulin with the date they were opened in one of two medication carts reviewed (1st Floor Back Medication Cart), failed to ensure that controlled refrigerated medications were stored in a separately locked, permanently affixed container in two of two medication refrigerators reviewed (second floor front and second floor back medication room refrigerators), and failed to label a bottle of testing solution when it was opened in one of two medication room refrigerators reviewed (second floor back medication refrigerator). Findings include: Manufacturer's directions for Insulin Lispro (Humalog - a fast-acting insulin used to lower blood sugar levels), dated November 2019, indicated that opened vials were to be thrown away after 28 days of use, even if there was insulin left in the vial. The facility's policy regarding medication labels, dated January 11, 2023, revealed that each…

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

Based on review of clinical records and interviews with staff, it was determined that the facility failed to maintain clinical records that were complete for one of 24 residents reviewed (Resident 29). Findings include: An Annual Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) for Resident 29, dated July 18, 2023, revealed that the resident was understood and could understand, required extensive assistance for all care, and had a diagnosis of diabetes (a group of diseases that result in too much sugar in the blood). A care plan for the resident, dated August 14, 2023, indicated that the resident had diabetes and that staff were to administer medications as ordered by the physician. A care plan for the resident, dated September 9, 2023, indicated that the resident was to participate with the restorative nurse program (helps residents practice activities of daily living to improve, or at least maintain, overall functioning) for ambulating related to the inability to ambulate without assistance and risk of decline. The resident was 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 a review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for two of 24 residents reviewed (Residents 1, 26). Findings include: The facility's policy regarding care plan development, dated January 11, 2023, revealed that based on the Minimum Data Set assessments (mandated assessments of a resident's abilities and care needs) and any other related information, an individualized, person-centered care plan would be developed to address problems/needs, goals, and approaches/interventions. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 12, 2023, revealed that the resident was cognitively impaired and required extensive assistance from staff for daily care needs. Observations of Resident 1 on October 10, 2023, at 11:03 a.m. revealed that she had a machine that is able to remotely check her…

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

Based on review of policies, as well as and clinical records and staff interviews, it was determined that the facility failed to ensure that the environment remained as free from accident hazards as possible, by not properly identifying residents with a high risk for elopement for one of 24 residents reviewed (Resident 33). Findings include: A facility policy for elopement, dated January 11, 2023, included that all residents at risk or those demonstrating attempts to leave the unit or building will have a photograph taken and available for all team members to view and use. The interdisciplinary team provides goals and approaches to address the elopement risk. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 33, dated September 14, 2023, revealed that the resident was cognitively impaired, exhibited wandering behaviors, required extensive assistance with daily care needs, and had diagnoses that included Alzheimer's disease. A care plan for Resident 33, dated August 10, 2023, indicated that the resident was 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.