Beacon Ridge

Based on review clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were provided with proper colostomy care for one of 40 residents reviewed (Resident 16).Findings include:The facility's policy regarding colostomy care (care for an artificial opening in the bowel), dated January 22, 2026, colostomy care will be provided per physician orders to provide the stoma with good skin care and check the condition of the stoma and surrounding skin.An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16 dated March 17, 2025,indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, had medical diagnosis that included intellectual disabilities and had an ostomy (a surgically created opening in the abdomen for bowel elimination. A review of Resident 16's clinical record revealed that there was no physician order for the resident colostomy size or orders to change the colostomy appliance. Interview…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents who were receiving enteral feedings (delivers liquid nutrients directly into the stomach) received appropriate treatment and services to prevent complications for one of 40 residents reviewed (Resident 43). Findings include: A facility policy for feeding tubes, dated January 22, 2026, indicated that the licensed practical nurse will change feeding tube dressings at least every 24 hours unless the physician's orders say otherwise and they are to document the dressing change in the resident's chart. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 43, dated February 20, 2026, indicated that the resident was cognitively impaired, had limited range of motion to her upper and lower extremity on one side, required assistance from staff for daily care needs, had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine from…

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

Based on observations, and staff interviews, it was determined that the facility failed to provide a separately locked, permanently affixed compartment in the refrigerator for the storage of controlled drugs (medications with the potential to be abused) in one of two medication rooms reviewed. Findings include:Observations in the facility's medication room on the Landings unit on April 22, 2026, at 1:11 p.m. revealed one small, locked refrigerator containing five bottles of liquid Ativan (a controlled medication used to treat anxiety). The liquid Ativan was not in a secured, locked compartment separate from other non-narcotic medications. Interview with Licensed Practical Nurse 1 at the time of the observation confirmed that the five bottles of liquid Ativan were not in a secured, locked compartment separate from other non-narcotic medications. Interview with the Nursing Home Administrator on April 22, 2026, at 1:40 p.m. confirmed the five bottles of liquid Ativan were not in a secured, locked compartment separate from other non-narcotic medications. 28 Pa. Code 211.9(a)(1) Pharmacy…

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 ensure that laboratory services were obtained as ordered by the physician for one of 40 residents reviewed (Resident 57).Findings include:Facility policy for Laboratory Services dated January 22, 2026, indicated that the facility will provide or obtain laboratory services to meet the needs of the residents, and will promote practices to ensure the quality and timeliness of laboratory services. The day shift unit nurse will fill out and send laboratory requests for newly ordered laboratory tests. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 57, dated March 29, 2026, indicated that the resident was cognitively intact, was independent with daily care needs, and had a history of urinary tract infection. Nurse's note for Resident 57 dated February 24, 2026, at 1:31 p.m. revealed that the resident complained of burning and pain on urination, that the physician was notified, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms for five of 38 residents reviewed (Resident 1, 13, 25, 29, 75). Findings include: The facility's policy regarding homelike environment, dated January 2, 2025, indicated that the facility staff and management were to the extent possible maximize the characteristics of the facility that reflect a personalized homelike setting including a clean, sanitary, and orderly environment. Observations of Resident 1's room on May 22, 2025, at 9:10 a.m. revealed that there was a large area of dried chipping paint, approximately 24 inches by 10 inches above the heating/cooling unit. Interview with the Maintenance Director on May 22, 2025, at 9:40 a.m. revealed that he was not aware of the chipping paint and indicated that with all the rain lately that moisture must be coming in the walls. An annual Minimum Data Set (MDS) assessment (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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated/revised to reflect a resident's specific care needs for three of 38 residents reviewed (Residents 35, 47, 50). Findings include: A facility policy regarding comprehensive person-centered care plans, dated January 2, 2025, indicated that comprehensive, person-centered care plans are 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). Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's conditions change. A quarterly MDS assessment for Resident 35, dated February 26, 2025, indicated that the resident was cognitively intact, required assistance with care needs, and had a diagnosis of hypertension (high blood pressure). A care plan for Resident 35, dated September 16, 2024, indicated that the resident was receiving a diuretic (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 facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling urinary catheters (a flexible catheter used to drain urine from the bladder into a drainage collection bag) for three of 38 residents reviewed who had an indwelling urinary catheter (Residents 4, 7, 10). Findings include: The facility's policy regarding urinary catheter care, dated January 2, 2025, indicated that staff are to be sure the catheter tubing and drainage bag are kept off the floor. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 7, 2025, revealed that the resident was severely cognitively impaired, required assistance with daily care, had an indwelling urinary catheter, and had a diagnosis of neuromuscular dysfunction of the bladder (nerve damage to the bladder). A care plan for Resident 4, dated March 19, 2023, revealed that the resident had an indwelling urinary catheter 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 facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a care plan was created to reflect the resident's specific care needs for one of 38 residents reviewed (Resident 7). Finding include: A facility policy, dated January 2, 2025, revealed that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. It will aid in preventing or reducing decline in the resident's functional status and/or functional levels and assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated, May 5, 2025, revealed that the resident was cognitively intact, required assistance with daily care needs, and had a diagnosis of Parkinson's disease. Clinical record review…

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

Based on a review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to safely transfer one of 38 residents reviewed (Resident 62) who required assistance from staff for transfers. Findings include: An admission minimum data set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated March 4, 2025, indicated that he was alert and oriented, required moderate assistance for daily care needs, and assist of one for transfers with wheeled walker and gait belt. Observations of Resident 62 on May 22, 2025, at 8:24 a.m. revealed that Nurse Aide 2 transferred the resident from a seated position to his wheelchair by using the back of his pants while there was a gait belt on the back of his wheelchair. Interview with Nurse Aide 2 on May 22, 2025, at 8:26 a.m. revealed that she was aware of Resident 62's transfer status and that she did not use a gait belt for the transfer instead she used the back of his pants for the transfer. Interview with Nursing Home Administrator on May 22, 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 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 one of 38 residents reviewed (Resident 35). Findings include: A facility policy regarding medication administration, dated January 2, 2025, indicated that the individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated February 26, 2025, indicated that the resident was cognitively intact, required assistance with care needs, and was taking an opioid medication (medications with the potential to be abused used to treat pain). Physician's orders for Resident 35, dated January 30, 2025, included an order for the resident to receive 5-325 milligrams (mg) of Hydrocodone-Acetaminophen (a narcotic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, manufacturer's instructions, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent. Findings include: A facility policy regarding medication administration, dated January 2, 2025, indicated that medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Each nurses' station has a current Physician's Desk Reference (PDR) and/or other medication reference available. Observations during medication administration on May 21, 2025, revealed that three medication administration errors were made during 29 opportunities for error, resulting in a medication administration error rate of 10.34 percent. 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 plans of corrections for State Survey and Certification (Department of Health) survey ending June 6, 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 May 22, 2025, identified repeated deficiencies regarding safety and accident hazards, failure to provide proper catheter care, and failure to ensure the accountability of controlled substances. The facility's plan of correction for a deficiency regarding safety and accident hazards, cited during the survey ending June 6, 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 facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to store food under sanitary conditions, failing to ensure that a microwave used to reheat resident food was clean (Bayside Nourishment Center), and failing to ensure that ice was made and stored in sanitary ice machines for one of two ice machines (Bayside Nourishment Center). Findings include: The facility's policy regarding food and supply storage, dated January 16, 2024, revealed that most, but not all, products contain an expiration date. The words sell-by, best-by, enjoy-by, or use-by should precede the date. The sell-by date is the last date that food can be sold or consumed; do not sell products in retail areas or place them on patient trays/resident plates past the date on the product. Foods past the use-by, sell-by, best-by, or enjoy by date should be discarded. Cover, label, and date unused portions and open packages. Products are good through…

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 provide nutritional supplements as ordered by the physician for one of 33 residents reviewed (Resident 1), failed to ensure that the hypoglycemic protocol was followed for two of 33 residents reviewed (Residents 3, 38), failed to ensure physician's orders for medications were followed for one of 33 residents reviewed (Resident 48); and failed to ensure that physician's orders for bowel protocols/medications were followed for two of 33 residents reviewed (Residents 7, 74). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 27, 2024 revealed that the resident was cognitively impaired and had the potential for decreased nutritional intake. Physician's orders, dated April 30, 2024, included orders for the resident to receive a four ounce Mighty Shake (nutritional supplement) with each meal. The resident's care plan, dated May 14, 2024, 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 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 two of 33 residents reviewed (Residents 7, 58). Findings include: The facility's policy regarding controlled substances, dated January 16, 2024, indicated that each controlled substance prescription is documented in the resident's medical record with the date, time and signature of the person administering the prescription. The prescription is recorded in the patient's health record and recorded on the Medication Administration Record (MARs). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated April 15, 2024, indicated that the resident was cognitively impaired, had pain occasionally, received pain medication routinely and as needed, received an opioid (a controlled pain medication). Physician's orders for Resident 7, dated January 9, 2023, included an order for…

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 anti-anxiety medications for one of 33 residents reviewed (Resident 58). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58, dated March 22, 2024, indicated that the resident was cognitively intact and had diagnoses that included anxiety. A care plan for the resident, dated November 9, 2021, revealed that the resident was at risk for mood decline/anxiety. If the resident had any signs/symptoms of anxiety, staff was to attempt to identify the source and eliminate it if possible. Staff will allow the resident to express feelings/concerns. Staff will offer emotional support and empathetic listening as needed. De-escalation preferences included music, books, TV, and friends. If the resident was restless, staff will check on the resident's needs (pain, hunger, thirst, toilet,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to properly date medications after they were opened in two of three medication rooms reviewed (Landings and Bayside), and failed to discard expired medical supplies. Findings include: The facility's policy regarding medication storage and disposal, dated [DATE], revealed that the facility would properly date medication vials after they were opened and remove outdated supplies from the facility inventory. Observations in the Landing medication room refrigerator on [DATE], at 12:12 p.m. revealed that there was one 30 ml (milliliter) bottle of Ativan opened and undated. Interview with Licensed Practical Nurse 6 on [DATE], at 12:18 p.m. confirmed that the Ativan was open and should have been labeled with the date it was opened. Observations in the Bayside medication room refrigerator on [DATE], at 12:24 p.m. revealed that there was one opened and undated multi-dose vial of insulin Glargine…

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 maintain compliance with nursing home regulations 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 State Survey and Certification (Department of Health) survey ending July 27, 2023, revealed that the facility developed plans of correction that included quality assurance systems with audits to ensure that the facility maintained compliance with cited nursing home regulations. The results of the audits were to be reported to the QAPI committee for review. The results of the current survey, ending June 6, 2024, identified repeated deficiencies regarding professional standards being met, quality of care, that the resident's environment was free of accident hazards, urinary catheter care, issues with oxygen therapy, preventing issues…

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 maintain the dignity of one of 33 residents reviewed (Resident 75) who had an indwelling urinary catheter. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 75, dated May 2, 2024, indicated that the resident was cognitively impaired, required partial to maximum assist with personal hygiene care, and had diagnoses that included stroke. A care plan for Resident 75, dated May 31, 2024, revealed that the resident had a Foley catheter (partially flexible tube that collects urine from the bladder and leads to a drainage bag) and that care included keeping her urine drainage bag covered in order to promote dignity. Physician's orders for Resident 75, dated May 30, 2024, included an order for the resident to have a Foley catheter. Observations of Resident 75 on June 5, 2024, at 8:54 a.m. revealed the resident lying in bed with her Foley catheter drainage bag attached to the side of 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 Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to clarify questionable physician's orders for one of 33 residents reviewed (Resident 5). 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. An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 5, dated May 7, 2024, indicated that the resident had moderate cognitive impairment, had pressure ulcers, and diagnoses that included a stroke. A care plan, dated April 30, 2024, revealed that Resident 5 was at risk for developing pressure ulcers,…

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 follow recommendations from a wound consultation for one of 33 residents reviewed (Resident 5). Findings include: An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 5, dated May 7, 2024, indicated that the resident had moderate cognitive impairment, pressure ulcers, and diagnoses that included a stroke. A care plan, dated April 30, 2024, revealed that the resident was at risk for developing pressure ulcers, and treatments were to be administered as ordered. A wound note, dated May 24, 2024, revealed the resident had a Stage III pressure ulcer on the right gluteus (buttocks) that measured 5.0 x 5.0 x 0.1 centimeters (cm) with recommendations to apply Santyl (removes dead tissue) to the area twice a day. However, the resident's Treatment Administration Record (TAR), dated May 2024, revealed that there was no documented evidence that Santyl was applied to the resident's right gluteus twice a day 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 review of policies, clinical records, and investigation documents, as well as observations and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards by failing to follow physician's orders and care-planned interventions for diets for one of 33 residents reviewed (Resident 29), failed to ensure that care-planned interventions were in place at the time of a fall for one of 33 residents reviewed (Resident 26), failed to follow physician's orders and care-planned interventions to prevent skin breakdown for one of 33 resident's reviewed (Resident 42), and failed to ensure that safe wheelchair transport techniques were used for one of 33 residents reviewed (Resident 79). Findings Include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 26, dated May 9, 2024, revealed that the resident was cognitively impaired, was dependent on staff for personal care needs, had diagnosis that included Alzheimer's disease, and had a history of falls. 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 review of policies and clinical records, as well as 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 33 residents reviewed (Resident 5) who had an indwelling urinary catheter. Findings include: The facility's policy regarding urinary catheter care, dated January 16, 2024, indicated that the catheter tubing and drainage bag were to be kept off the floor. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated May 7, 2024, revealed that the resident had moderate cognitive impairment, had an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine), and had diagnoses that included neurogenic bladder (bladder dysfunction caused by nervous system conditions). Physician's orders, dated April 29, 2024, included an order for the resident to have an indwelling urinary catheter. Observations of Resident 5 on June 5, 2024, at 9:13 a.m. revealed that the 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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that oxygen tubing and a nasal canula remained off the floor for one of 33 residents reviewed (Resident 42). The facility's policy regarding oxygen therapy, dated January 16, 2024, indicated that oxygen was to be administered safely and in accordance with physician's orders. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated March 5, 2024, revealed that the resident was cognitively impaired and had diagnoses that included chronic respiratory failure with hypoxia (a serious condition that causes low blood oxygen) and a history of generalized anxiety. A care plan, dated August 29, 2023, indicated that Resident 42 was to receive continuous oxygen while sleeping due to a respiratory disease. Physician's orders for Resident 42, dated April 11, 2024, included an order for the resident to receive continuous oxygen at a flow rate of 2 liters per minute via nasal…

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 a physician's order for an invasive procedure to collect a specimen for a laboratory test for one of 33 residents reviewed (Resident 58). Findings include: The facility's policy regarding intermittent catheterization (the insertion and removal of a catheter several times a day to empty the bladder), dated January 16, 2024, indicated that staff was to verify that there is a physician's order for this procedure. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58, dated December 25, 2024, revealed that the resident was usually understood and could usually understand others. A care plan for the resident, dated September 23, 2021, indicated that the resident had a potential for discomfort due to urinary retention (when the bladder does not empty completely or at all). Staff was to perform intermittent catheterization as ordered by the physician and as needed. Physician'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 clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided the proper food consistency as ordered by the physician for one of 33 residents reviewed (Resident 29). This deficiency was cited as past non-compliance. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated February 20, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included Cerebral Vascular Accident (CVA - commonly known as a stroke) with hemiplegia (paralysis on one side of the body). A care plan for the resident, dated September 7, 2022, revealed that the resident had an Activities of Daily Living (ADL) self-care performance deficit related to a left hemiplegia, and that the resident was able to feed herself after set up. A care plan, dated September 8, 2018, revealed that the resident had a potential nutritional problem related to CVA and dysphagia (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 and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during wound care for two of 33 residents reviewed (Residents 45, 59). Findings include: The facility's policy regarding hand hygiene, dated January 16, 2024, indicated that hand hygiene is an important infection control measure to prevent illness in skilled nursing homes, and that hands should be sanitized or washed before and after the use of gloves. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 59, dated April 21, 2024, revealed that the resident was moderately cognitively impaired, had diagnoses that included peripheral vascular disease (a circulatory condition that reduces blood flow to the limbs). Physician's orders, dated May 24, 2024, included an order to cleanse the left foot with normal saline solution, pat dry, apply betadine, a heel cushion and soft rolled gauze wrap. Observations on June 4,…

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.