Julia Pound Care Center

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 33 residents reviewed (Residents 27, 60). Findings include: A facility policy regarding care plans, dated March 12, 2025, indicated that the facility will comprehensively evaluate and re-evaluate a resident's need for service and develop a plan to promote their highest practicable level of functioning. The care plan will be reviewed and evaluated for intervention effectiveness and updated electronically as needed. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated May 20, 2025, indicated that the resident was cognitively intact, required assistance with care needs, had limited range of motion (the full movement potential of a joint) to her lower extremities on both sides, and had diagnoses that included muscular dystrophy (disease that causes progressive…

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 two of 33 residents reviewed (Resident 42, 72). Findings include: A facility policy for medication administration, dated March 12, 2025, indicated that the individual who administers the medication records the administration on the resident's Medication Administration Record (MAR) directly after the medication is given. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated May 15, 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 42, dated October 23, 2024, included an order for the resident to receive two 50 milligrams (mg) tablets of Tramadol (a narcotic pain medication) to equal 100 mg every eight…

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 carts reviewed (Highlands 1 and Highlands 2), and failed to discard expired medical supplies in one of two medication rooms reviewed (Highlands). Findings include: The facility's policy regarding medication storage, dated [DATE], revealed that the facility would store medications and biologicals safely, securely and properly. In addition, when the original seal of the manufacturer's container is initially broken, a date opened and expired date sticker shall be placed on the container. Observations in Highlands medication cart 2 on [DATE], at 9:36 a.m. revealed that there were two containers of 1 percent diclofenac sodium (pain reliever) topical gel, one container of 0.1 percent triamcinolone (steroid used to decrease inflammation) cream, and two containers of 12 percent ammonium lactate (treats dry itchy skin)…

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 July 11, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending June 5, 2025, identified repeated deficiencies related accuracy of assessments, care plan timing and revision, pharmacy services, and food safety. The facility's plan of correction for a deficiency regarding accuracy of assessments, cited during the survey ending July 11, 2024, revealed that accuracy of assessments would be monitored by QAPI. 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 a 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 33 residents reviewed (Resident 67). Findings include: Current 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 control intervention designed to reduce transmission of resistant…

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 physician's orders were followed, resulting in significant medication errors for one of six residents reviewed (Resident 3). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 3, dated November 14, 2024, revealed that the resident was sometimes understood, could sometimes understand others, and had diagnosis which included diabetes and dementia. Physician's orders for Resident 3, dated November 1, 2024, included for the resident to have her blood glucose (amount of sugar in the blood) level checked before meals and at bedtime, receive 25 units of Lantus Solostar (long-acting insulin used to treat high blood sugar) twice a day, and 6 units of insulin lispro (fast acting insulin used to treat high blood sugar) three times a day. Physician's orders, dated November 1, 2024, also included for the resident to receive 2 units of insulin lispro if her blood sugar was between 150 milligrams…

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 five residents reviewed (Resident 3). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 3, dated November 14, 2024, revealed that the resident was sometimes understood, could sometimes understand others, and had diagnoses that included diabetes and dementia. Physician's orders for Resident 3, dated November 1, 2024, included that the resident receive 5 milligrams (mg) of olanzapine (used to treat the symptoms of schizophrenia) at bedtime. Review of Resident 3's Medication Administration Record (MAR), dated November 2024, revealed that there was no documented evidence that the resident received this medication on November 11, 2024, or on November 29, 2024. Physician's orders for Resident 3, dated November 1, 2024, included that the resident receive two 325 mg tablets of Tylenol at bedtime. Review of the resident's MAR, dated November 2024 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 clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of five residents reviewed (Resident 3). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 3, dated November 14, 2024, revealed that the resident was sometimes understood, could sometimes understand others, and had a diagnosis which included diabetes and dementia. Review of nurse aide documentation, dated December 3, 2024, revealed that the resident ate 100 percent of her lunch meal. Review of a grievance investigation related to Resident 3, dated December 3, 2024, revealed that Resident 3's lunch tray was removed from her room at 3:45 p.m. by the Director of Nursing, and the resident did not eat anything on that tray. Interview with the Director of Nursing on December 16, 2024, at 4:20 p.m. confirmed that nurse aide documentation of the resident's lunch meal on December 3, 2024, was…

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 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 37 residents reviewed (Residents 67, 80). Findings include: A facility policy for medication administration, dated January 11, 2023, indicated that the individual that administers the medication dose records the administration on the resident's MAR directly after the medication is given. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 67, dated May 11, 2024, indicated that the resident was cognitively intact, was dependent on staff for her daily care needs, and had diagnoses that included urinary tract infection and paraplegia (paralysis that occurs in the lower half of the body). Physician's orders for Resident 67, dated November 22, 2023, included an order for the resident to receive 5 milligrams (mg)/325 mg of Hydrocodone-Acetaminophen (a narcotic pain medication) every eight 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 policies, observations, and staff interviews, it was determined that the facility failed to ensure that nutritional drinks in the medication room and pantry were not expired (Crossroads). Findings include: The facility policy regarding food storage, dated March 13, 2024, revealed that food is stored under safe and sanitary conditions to prevent injury and food-borne illness. Observations in the Crossroads medication room on July 10, 2024, at 8:30 a.m. revealed that there were nine Nepro nutritional milkshakes (a protein drink generally used for dialysis residents) that expired in June 2024. Observations in the Crossroads pantry refrigerator on July 10, 2024, at 8:51 a.m. revealed that there were nine Nepro nutritional milkshakes that expired in May 2024. Interview with the Dietary Manager on July 10, 2024, at 8:58 a.m. confirmed that 18 expired Nepro nutritional milkshakes were in circulation on the Crossroads unit and should have been previously discarded. 28 Pa code 211.6(f) Dietary Services.

Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 37 residents reviewed (Resident 60). Findings include: A significant Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 60, dated June 14, 2024, revealed that the resident was cognitively intact, was clearly understood and able to understand others, required assistance with care needs, had an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), had a urinary tract infection (infection involving any part of the urinary system including the kidney, ureters, bladder and urethra) in the last 30 days, and had a diagnosis that included neurogenic bladder (bladder lacks control due to nerve or muscle problems). Clinical record review for Resident 60 revealed that she had a care plan, dated February 12, 2024, for an indwelling catheter that included an intervention to provide…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to address and document the opportunity to formulate advance directives and failed to document in the resident's clinical record the resident's decision to accept or decline assistance to formulate advance directives for one of 37 residents reviewed (Resident 70). Findings include: The facility's policy regarding advance directives (instructions regarding the provision of health care and life sustaining measures when the resident is incapacitated), dated March 13, 2024, indicated that if the resident does not have an advance directive, facility staff must inform the resident or resident representative of their right to establish one as set forth in the laws of the state and provide assistance if the resident wishes to execute one or more directive(s). Facility staff must document in the resident's medical record these discussions and any advance directive(s) that the resident executes. A quarterly Minimum Data Set (MDS) assessment (a mandated 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.

Based on observations and staff interviews, it was determined that the facility failed to provide a clean, homelike environment for one of 37 residents reviewed (Resident 27). Findings include: The facility's policy titled housekeeping department operations, dated March 13, 2024, revealed that the policy objective was to provide a safe, clean environment for residents. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated July 3, 2024, revealed that the resident was cognitively intact, required assistance with most daily care needs, and had diagnoses that included heart failure and osteoarthritis (a type of arthritis that effects the bone). Observations of Resident 27 sitting in his wheelchair on July 8, 2024, at 11:42 a.m. and July 9, 2024, at 12:18 p.m. revealed that there was a moderate accumulation of removable dust/debris on the wheels and the metal supports under the chair. Interview with Housekeeper 1 on July 9, 2024, at 2:05 p.m. confirmed that Resident 27's wheelchair was cleaned in June 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 facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse from a resident who wanders for one of 37 residents reviewed (Resident 64). Findings include: The facility's policy for abuse, dated March 13, 2024, indicated each resident is provided with a safe environment where they are not subject to mental, physical, verbal, and sexual abuse. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies, serving the resident, family members, or legal guardians, friends, or other individuals. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A quarterly Minimum Data Set (MDS) assessment (a mandated…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian in writing regarding the reason for hospitalization for four of 37 residents reviewed (Residents 23, 36, 46, 67). Findings include: A significant Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated June 24, 2024, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included dementia. Nursing notes for Resident 23, dated June 16, 2024, at 10:30 a.m. and 4:56 p.m., revealed that the resident was unresponsive, then vomited bright red blood and clots. She was transferred to the hospital and admitted with GI (gastro-intestinal) bleeding. There was no documented evidence that a written notice of Resident 23's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer. A quarterly MDS assessment for Resident 36, dated April 24, 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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or the responsible party was notified about the facility's bed-hold policy upon transfer to the hospital for four of 37 residents reviewed (Residents 23, 36, 46, 67). Findings include: The facility's policy for Bed Holds, dated March 13, 2024, indicated that all residents and/or their representatives shall be notified of the bed-hold policy, in writing through the admission agreement, on or before admission and upon transfer to the hospital. A significant Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated June 24, 2024, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included dementia. Nursing notes for Resident 23, dated June 16, 2024, at 10:30 a.m. and 4:56 p.m., revealed that the resident was unresponsive, then vomited bright red blood and clots. She was transferred…

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 the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for three of 37 residents reviewed (Residents 103, 104, 105). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that an admission MDS assessment was to be completed no later than 14 days following admission. An admission MDS assessment for Resident 103, dated March 31, 2024, revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on April 8, 2024, which was 15 days after admission. An admission MDS assessment for Resident 104,…

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 the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of 37 residents reviewed (Residents 60, 64). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that Section N0415F (Antibiotic Medications - medications used to treat infections) was to be coded if the resident took the medication during the seven-day look-back period. Physician's orders for Resident 60, dated June 8, 2024, included an order for the resident to receive one gram of Ceftazidime (antibiotic medication) intravenously (administration of fluids and/or medications directly into a person's vein) every eight hours for seven days for a urinary tract infection (infection involving any part of the urinary system including the kidney, ureters, bladder and urethra).…

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 baseline care plans included the information and instructions needed to provide person-centered care for two of 37 residents reviewed (Residents 25, 35). Findings include: The facility's policy regarding care plans, dated March 13, 2024, indicated that a baseline care plan is person-centered care plan designed to include the resident's basic healthcare information needed to care for the resident. It must be completed within forty-eight hours of admission and include initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, address resident health and safety concerns, and identify needs for supervision, behavioral interventions, and assistance with care as necessary. The comprehensive care plan, which is derived from the baseline care plan and is triggered by care area assessments, will be entered into the electronic health record system. A quarterly 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 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 care needs for one of 37 residents reviewed (Resident 60). Findings include: A significant Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 60, dated June 14, 2024, revealed that the resident was cognitively intact, was clearly understood and able to understand others, required assistance with care needs, had a foley catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), had a urinary tract infection (infection involving any part of the urinary system including the kidney, ureters, bladder and urethra) in the last 30 days, and had a diagnosis that included neurogenic bladder (bladder lacks control due to nerve or muscle problems). Physician's orders for Resident 60, dated February 24, 2024, indicated that the resident was ordered 50 milligrams of Nitrofurantoin daily every Monday, Wednesday, and Friday for history 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 staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for two of 37 residents reviewed (Residents 62, 80). Findings include: The facility's policy regarding medication administration, dated March 13, 2024, revealed that medications are administered as prescribed in accordance with good nursing principles and only by persons legally authorized to do so. Right resident, right drug, right dose, right route, and right time are applied for each medication being administered. Medications are administered in accordance with written orders of the prescriber. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated May 2, 2024, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and had diagnoses that included atrial fibrillation (irregular heart beat) and dementia. Physician's orders for Resident 62, dated December 2,…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to obtain the required information from the contracted hospice provider for two of four hospice residents reviewed (Residents 8, 34). Findings include: The facility's policy regarding the hospice program, dated March 13, 2024, indicated that the resident acknowledges that he or she has been given a full explanation and understands the purpose of hospice care, with the focus on providing comfort and support to the resident. The hospice provider will have a contract with the facility and a modified plan of care. An quarterly MDS assessment for Resident 8, dated June 14, 2024, revealed that the resident was moderately cognitively intact, required assistance from staff for her daily care needs, and was receiving hospice services (end-of-life services). A hospice Election of Benefit document (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness) for Resident 8, dated August 23, 2023,…

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 August 13, 2023, and a complaint investigation survey ending May 29, 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 July 11, 2024, identified repeated deficiencies related to a failure to ensure the accuracy of Minimum Data Set (MDS) assessments, resident records being complete and accurate, and hospice services. The facility's plan of correction for a deficiency regarding the accuracy of 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.

Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for three of five residents reviewed (Residents 1, 2, 5). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 30, 2024, revealed that the resident was cognitively intact, was dependent on staff for personal hygiene care, and had diagnoses that included dementia. Review of nurse aide documentation for Resident 1, dated March and April, 2024, revealed that care provided by a nurse aide was not documented by the dayshift nurse aide on March 4, 9, 27, and April 15, 16, 18, 20, 22, 24, 2024. A quarterly MDS assessment for Resident 2, dated May 24, 2024, revealed that the resident was cognitively intact, required substantial to maximum assist for personal hygiene care, and had diagnoses that included Multiple Sclerosis. Review of nurse aide documentation for Resident 2, dated March, April, 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 a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's dignity was maintained for one of 38 residents reviewed (Resident 1). Findings include: The facility's policy regarding call lights, dated April 26, 2023, indicated that staff members who are alerted of an activated call light are responsible for responding promptly to promote a secure atmosphere for residents. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 22, 2023, revealed that the resident was alert and oriented, able to make her needs known, and required extensive assistance from staff for daily care needs including toileting, hygiene, and transfers. Interview with Resident 1 on August 28, 2023, at 11:51 a.m. revealed that she had to wait for an extended period of time for staff to respond to her call bell. She stated that she had a bowel movement and waited 53 minutes for staff to assist her off the bed pan. A call bell…

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 prompt efforts were made to resolve grievances/concerns for one of four residents reviewed (Resident 4). Findings include: The facility's policy regarding grievance, complaints, and suggestions, dated April 26, 2023, indicated that when a resident or their representative voices a concern to direct care providers about resident services or service decisions, it would be documented by the staff member on a Corporate Grievance Complaint and or Suggestion Form and communicated to the supervisor on the date the concern was known. Resolution of the concern was desired within three to five working days from the date the concern was filed. Resident Council meeting minutes, dated June 9, 2023, revealed that when asked about nursing services, Resident 4 reported that he had waited one hour to be helped. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated August 2, 2023, 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 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 four residents reviewed (Resident 2). The deficiency is being cited as past non-compliance. Findings include: The facility's policy on transcription of physician orders, dated April 26, 2023, indicated that physician orders will be transcribed accurately with the date of order, frequency, and reason for treatment. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 14, 2023, indicated that the resident was cognitively intact, required extensive assist for daily care needs, and had diagnosis that included high blood pressure, diabetes mellitus, and fracture of the lower end of right tibia (bone located in the lower leg). A fracture clinic consultation report for Resident 2, dated July 18, 2023, and completed by a physician, revealed that the resident was at the clinic for follow-up related to a fractured right leg. Physician's orders…

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.