Embassy Of Huntingdon Park

Based on facility policy, clinical record reviews, observations, and staff and resident interviews, it was determined that the facility failed to honor food preferences for one of 47 residents reviewed (Resident 26).Findings include: The facility's policy regarding nutrition services, dated July 10, 2025, for Patient Menu Selection indicated the purpose is to ensure patients' preferences are taken into consideration when menu selections are placed. Patient food preferences are respected and appropriate dietary substitutions are made. Situations might include patients with strong likes/dislikes, patients hospitalized for long lengths of time, ethnic food preferences and those observing cultural or religious dietary laws. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 26, dated December 17, 2025, indicated that the resident was cognitively intact, required assistance with care, and was independent with eating after set-up. A nutritional care plan for Resident 26, dated March 16, 2025, indicated that the…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending April 10, 2025, and complaint surveys ending August 19, 2025 and February 10, 2026, 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 5, 2026, identified repeated deficiencies related to quality of care, food storage/prepare/serve-sanitary, and infection control.The facility's plan of correction for a deficiency regarding quality care, cited during the surveys ending April 10, 2025, August 19, 2025, 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 observations and staff interviews, it was determined that the facility failed to ensure that appropriate signage was posted for a resident with special infection control isolation needs for three of 47 residents reviewed (Residents 35, 89, 90). Findings include:The facility's policy regarding isolation precautions, dated July 10, 2025, indicated that isolation precautions were to be implemented when a resident had an indwelling catheter and staff were to post the appropriate isolation sign on the room entrance door.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated February 19, 2026, revealed that the resident was cognitively intact and that he had an indwelling urinary catheter. The resident's care plan, dated February 14, 2026, indicated that the resident had a Foley catheter. Physician's orders for Resident 35, dated February 15, 2026, included an order for the resident to have a urinary catheter.An admission MDS assessment for 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 a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to honor the resident and the responsible party's right to make informed decisions regarding his/her treatment for one of eight residents reviewed (Resident 1).Findings include:A facility policy for residents' rights regarding treatment and advanced directives dated December 10, 2025, indicated that it is the policy of the facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advanced directives. An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 1, dated January 4, 2026, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, had diagnosis that included cirrhosis of the liver (condition in which the liver is scarred and permanently damaged), and was receiving Hospice (program that gives special care to people who are near the end of life)…

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

Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of eight residents reviewed (Resident 1) and failed to assess a wound for one of eight residents reviewed (Resident 2). Findings include:An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 1, dated January 4, 2026, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, had diagnosis that included cirrhosis of the liver (condition in which the liver is scarred and permanently damaged), and was receiving Hospice (program that gives special care to people who are near the end of life) services. Physician's orders for Resident 1 dated January 4, 2026, included for the resident to receive 500 milligrams (mg) of Cipro (an antibiotic) every morning and at bedtime for purulent (a thick, often yellowish or greenish fluid that indicates an active bacterial infection) drainage for 10 days. Review of the Medication Administration…

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, clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcers were treated with the current physician's orders for one of 8 residents reviewed (Resident 4). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated January 4, 2026, revealed that the resident was confused, required extensive assistance with daily care needs, and had pressure ulcers. Physician's orders for Resident 4, dated, February 4, 2026, was for the right foot to be cleansed with soap and water, apply Calmoseptine, then a heel cup, and to change daily.A Certified Registered Nurse Practioner (CRNP - an advanced practice registered nurse that can work independent of a physician) wound nurse note for Resident 4, dated February 3, 2026, revealed that the resident's treatment to the pressure ulcer on her right heel had changed from Gentamicin to Calmoseptine. A review of Resident 4's Treatment Administration Record (TAR) for February…

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 observations, as well as staff interviews, it was determined that the facility failed to provide an environment free from accident hazards. Findings include: The facility's policy for Oxygen, dated December 10, 2025, revealed that portable oxygen tanks would be stored in a safe manner, in an upright position.Observations of the 100 hall, short side, on February 10, 2026 at 1:45 p.m. revealed there was a metal stretcher with a full portable oxygen tank laying on the middle section, unsecured. The stretcher was parked outside of resident's rooms and was within reach of the residents.Interview with Licensed Practical Nurse 1 on February 10, 2026 at 1:45 p.m. revealed that the oxygen tank should not have been stored in the hallway on the stretcher. She further stated she did not know why the stretcher was there either.Interview with the Regional Nurse on February 10, 2026 at 2:02 p.m. revealed that the oxygen tank should have been stored securely and not laying on a stretcher in the hallway. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for one of seven residents reviewed (Resident 2). Findings include: The facility policy for medication administration dated July 10, 2025, indicated that medications are administered by licensed nurses, or other staff that are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated June 24, 2025, revealed that the resident was cognitively intact, required assistance with personal care needs, and had diagnoses that included heart failure. Physician's orders for Resident 2 dated October 31, 2024, included an order for the resident to receive 50 milligrams (mg) of Metoprolol Succinate (medication used to treat high blood pressure) every day for hypertension (high…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for one of seven residents reviewed (Resident 3). Findings include: The facility's policy for wound management, dated July 10, 2025, indicated that wound treatments would be provided in accordance with physician's orders, including the cleansing method, type of dressing, and frequency of dressing change.A quarterly Minimum Data Set (MDS) assessment for Resident 3, dated July 16, 2025, revealed that the resident was understood and could understand, was cognitively impaired, was incontinent of bowel and bladder, and was at risk for developing pressure ulcers. A nursing note, dated August 15, 2025, at 8:30 p.m. revealed that Resident 3 had a fluid filled blister to the right abdomen measuring 1.5 x 1.5 centimeters (cm). Physician's orders, dated August 15, 2025, included an order for skin prep (protective barrier) to be applied to the blister on her abdomen every day and evening…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 34 residents reviewed (Resident 20), failed to administer insulin per manufacturer's instructions for one of 34 residents reviewed (Resident 78), and failed to follow wound recommendations for one of 34 residents reviewed (Resident 80). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 20, dated March 3, 2025, indicated that the resident was cognitively intact, received insulin, and had diagnoses that included diabetes. Physician's orders for Resident 20, dated March 19, 2025, included an order for the resident to receive 17 units of Humalog (fast acting insulin) subcutaneously with meals for diabetes. The insulin was to be held if the resident's blood sugar was less than 100 milligrams/deciliter (mg/dL) The Medication Administration Record (MAR) for Resident 20 for January, March, and April 2025 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.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow pressure ulcer treatment recommendations from a wound consultation for one of 34 residents reviewed (Resident 11). Findings include: The facility's wound treatment policy, dated January 9, 2025, revealed that to promote wound healing of various types of wounds, it was the policy of the facility to provided evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments would be provided in accordance with physician orders, and in the absence of treatment orders, the licensed nurse would notify the physician to obtain treatment orders. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated March 12, 2025, indicated that the resident was cognitively impaired, required assistance for her care needs, and had a Stage 3 pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: The facility's policy regarding food safety, dated January 9, 2025, indicated that all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption, and all food should be covered labeled and dated with the date it was opened. Observations in the walk-in cooler on April 7, 2025, at 9:20 a.m. revealed that there were five trays of chicken and five trays of broccoli that were covered with plastic wrap and not dated with the date they were prepared. Observations in the walk-in freezer on April 7, 2025, at 9:30 a.m. revealed that there were opened bags of carrots, green beans, corn and dinner rolls not secured and not labeled with the date they were opened. Observations in the main kitchen on April 7, 2025, at…

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 staff reported an allegation of verbal abuse in a timely manner for one of 34 residents reviewed (Resident 5). Findings include: The facility's abuse policy, dated January 9, 2025, indicated that staff would report any incidents of suspected abuse immediately to administration. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 17, 2025, indicated that the resident was cognitively impaired, required assistance from staff with daily care tasks, and had diagnoses that included hydrocephalous (excess of fluid on the brain). Facility investigation documents, dated January 10, 2025, revealed that Nurse Aide 1 was assisting Nurse Aide 2 transfer Resident 5 to her wheelchair on January 5, 2025, at breakfast. Nurse Aide 1 heard Nurse Aide 2 yelling loudly at Resident 5. The resident asked the nurse aide if she could have her shoes on…

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 obtain laboratory studies as ordered by the physician for one of 34 residents reviewed (Resident 27). Findings include: A facility policy related to anticoagulation therapy, dated January 9, 2025, indicated that the facility will implement the procedure for the treatment/management of residents receiving anticoagulation therapy (i.e. low molecular weight heparin or warfarin/coumadin). The facility in collaboration with the physician will provide therapeutic coagulation for the resident while attempting to decrease the potential morbidity and mortality associated with anticoagulation therapy. The charge nurse will obtain an order from the physician for any pertinent labs for monitoring of the anticoagulation therapy. The nurse will notify the physician and document the results of the prothrombin time and international normalized ratio (PT/INR-blood tests that determine how long it takes the blood to clot). A quarterly Minimum Data Set (MDS) assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 34 residents reviewed (Resident 41). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection…

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

Based on facility requirements according to the Affordable Care Act (ACA), review of Payroll Based Journal (PBJ) Staffing Data Reports, and staff interviews, it was determined that the facility failed to electronically submit direct care staffing information for one of four quarters reviewed (fiscal year quarter one 2024). Findings include: Review of Section 6106 of the ACA requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data to the Centers for Medicare and Medicaid Services (CMS). Submission must be received by the end of the 45th calendar day (11:59 p.m. Eastern Standard Time) after the last day of each fiscal quarter to be considered timely. First quarter reporting includes data from October 1st through December 31st and is due by February 14th. Second quarter reporting includes data from January 1st through March 31st and is due by May 15th. Third quarter reporting includes data from April 1st through June 30th and is due by August 14th. Fourth quarter reporting includes July…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for three of 29 residents reviewed (Residents 28, 39, 75). Findings include: The facility's policy regarding care plans, dated April 16, 2024, indicated the comprehensive care plan will be reviewed and revised as necessary, when a resident experiences a status change. The care plan will be updated with the new or modified interventions. An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 28, dated March 26, 2024, revealed that the resident was understood, able to understand what was being said, required assistance with care needs, had an unstageable pressure ulcer to sacrum, received intravenous therapy (administration of fluids and/or medications directly into a person's vein), and received an antibiotic. A care plan for Resident 28, dated March 22, 2024, revealed that the resident had a midline…

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 flush an intravenous (IV) line and to change an intravenous line dressing and caps (caps that disinfect IV ports) as ordered by the physician for one of 29 residents reviewed (Resident 48). Findings include: The facility's policy regarding intravenous (IV) catheters (a tube placed in a vein that can be used to deliver fluids and/or medications), dated September 17, 2019, revealed that when a resident was ordered intravenous medication, a 10 milliliter (ml) saline flush (a method used to clean a catheter of blood or medication) was to be administered before and after each medication that was infused. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 48, dated April 7, 2024, indicated that the resident was cognitively intact and received IV medications. A nursing note, dated April 1, 2024, at 11:15 a.m., revealed that Resident 48 was admitted to the facility and had a double lumen (two…

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

Based on facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that ice was prepared and stored under sanitary conditions in one of two ice machines observed, and failed to ensure that food in the main kitchen was stored in accordance with professional standards for food service safety. Findings include: The facility policy for cleaning the ice machines and ice storage containers, dated April 16, 2024, indicated that all ice machines will be cleaned monthly, at a minimum, with approved sanitizing agent. Observations of the second-floor ice machine on the May 21, 2024, at 8:20 a.m. revealed a dark, removable substance on the inside of the ice machine in the area where water flows and ice is dispensed. Interview with the Assistant Maintenance Director on May 21, 2024, at 1:51 p.m. confirmed that the ice machine had a dark, removable substance inside the ice machine. He stated that he had cleaned the first-floor ice machine at the beginning of the month and that the machine on the second floor was overdue to be cleaned. Cleaning…

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 appropriate services to maintain personal grooming and hygiene for one of 29 residents reviewed (Resident 13) who was dependent for care. Findings include: The facility's policy regarding personal care, dated April 16, 2024, revealed that nail care cleaning and trimming should be completed as needed, unless the resident is a diabetic or has another reason it should not be done. In such cases a nurse or podiatrist (a medical specialist who helps with problems that affect feet or lower legs) will provide care. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated February 19, 2024, revealed that the resident was understood, could understand others, and had diagnoses that included Alzheimer's and dementia. The resident's care plan, dated February 26, 2020, revealed that the resident had an Activities of Daily Living (ADL) self-care performance deficit…

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

Based on review of clinical records and facility investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that interventions were in place and functioning to prevent behaviors for one of 29 residents reviewed (Resident 66). Findings include: An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 66, dated February 4, 2024, revealed that the resident was understood, was able to understand what was being said, was cognitively intact, had behaviors affecting others, and required assistance with care needs. A care plan for Resident 66, dated January 30, 2024, revealed that the resident was observed displaying sexually inappropriate behavior. Review of a facility incident report, dated February 29, 2024, revealed that it was reported by staff that Resident 66 had his hand on another resident's genitals over his pants in the hallway. The other resident was removed from the situation and the registered nurse was made aware. It was noted that both residents…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for two of 29 residents reviewed (Residents 28, 48). Findings include: The facility's policy regarding medication administration, dated April 16, 2024, indicated that staff were to sign the Medication Administration Record (MAR) after administering medications and if the medication was a controlled substance, staff were to sign the narcotic book. An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 28, dated March 26, 2024, revealed that the resident was understood, able to understand what was being said, required assistance with care needs, had an unstageable pressure ulcer to sacrum, and had complaints of pain. A physician's order for Resident 28, dated March 29, 2024, included an order for the resident to receive 2.5 milligrams (mg) of oxycodone (narcotic pain reliever) 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 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 correction for a State Survey and Certification (Department of Health) surveys ending April 27, 2023, and July 21, 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 May 21, 2024, identified repeated deficiencies regarding care plan timing and revision, grooming and personal and oral hygiene, and ensuring that the resident's environment remained free from accident hazards. The facility's plan of correction for a deficiency regarding a failure to update resident care plans, cited during the survey ending April 27,…

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.