Jersey Shore Skilled Nursing And Rehabilitation Ce

Based on observation and staff and resident interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to maintain a clean and odor free environment on two of three nursing units (First and Second Floor Nursing Units, Residents 13, 31, and 92). Findings include: Observation of Resident 13's room on March 24, 2026, at 10:46 AM revealed Resident 13 was seated on the side of her bed. The bed sheets were visibly soiled with a large yellow and light brown stain. There was a strong urine odor in the room and adjacent hallway. A subsequent observation at 12:24 PM revealed Resident 13's sheets were changed but the urine odor remained. Observation of Resident 13's room on March 25, 2026, at 10:02 AM revealed Resident 13 was seated on the side of her bed. The bed sheets were visibly soiled with a large dark yellow stain. A subsequent observation at 11:41 AM revealed Resident 13 was standing beside her bed, changing her soiled bed sheets. There was a strong urine odor in the room and adjacent hallway. The above concerns for Resident 13 were…

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 review and staff interview, it was determined that the facility failed to implement a comprehensive, person-centered care plan for resisting care one of 23 residents reviewed (Resident 82). Findings include: Clinical record review revealed the facility admitted Resident 82 on May 1, 2025. Nursing documentation dated January 22, 2026, at 3:47 AM revealed there was a strong smell of ammonia emanating from the room, out into the hallway. Resident 82's entire bed was visibly wet from urine. Resident appeared not to have been changed for several hours with saturated brief and bed linens. Licensed practical nurse noted Resident 82's sacrum was red from her incontinence of bowel and bladder. Nursing documentation dated January 23, 2026, at 2:00 AM revealed the nurse was called to assist the nurse aides with care. Resident 82 was observed hitting and threatening staff. The nurse explained to Resident 82 that her bed and brief was soiled, and Resident 82 continued yelling at staff. The licensed practical nurse notified the registered nurse supervisor of Resident 82's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview it was determined that the facility failed to implement care and services to maintain activities of daily living (ambulation) for one of three residents reviewed for declines in activities of daily living (Resident 6). Findings include: Clinical record review for Resident 6 revealed an active physician order dated March 16, 2025, that instructed that Resident 6 was to transfer with the assistance of one staff, then was to walk with a front-wheeled walker from her room to the E hallway window with chair to follow behind. An annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated May 8, 2025, indicated Resident 6 required partial to moderate assistance of staff to walk 10 feet and to transfer to and from a bed to a chair (or wheelchair). A physical therapy Discharge summary dated [DATE], included the instructions for a restorative nursing program (RNP) that included range-of-motion treatment 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 clinical record review, observation, and staff interview, it was determined that the facility failed to provide appropriate care and services for supplemental oxygen use for one of two residents reviewed for oxygen administration concerns (Resident 16).Findings include: Observation of Resident 16 on March 24, 2026, at 2:12 PM revealed him to have supplemental oxygen in use via a room concentrator (machine that draws in room air and condenses the oxygen saturation of the room air to administer supplemental oxygen to a resident at 90 percent or higher through a mask or nasal cannula (NC, flexible tubing with prongs at one end that insert into the nares) set at four liters per minute (4 l/m). Clinical record review for Resident 16 revealed an active physician order dated February 20, 2026, for staff to administer supplemental oxygen as needed (PRN) at two liters per minute (2 l/m) via nasal cannula (NC) when short of breath (SOB) for comfort. Observation of Resident 16 with Employee 1 (licensed practical nurse) on March 27, 2026, at 8:38 AM confirmed that Resident 16 continued…

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 employee personnel record review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for one of one nurse aides reviewed (Employee 5).Findings include: Review of Employee 5's (nurse aide) personnel file revealed a hire date of July 5, 2023. There was no evidence the facility completed an annual performance evaluation for Employee 5 at least once every 12 months. Upon request to facility administration the facility could not provide any completed performance evaluations for Employee 5. Interview with the Nursing Home Administrator and Director of Nursing on March 27, 2026, at 11:45 AM confirmed that a performance evaluation was not completed annually for Employee 5. 28 Pa. Code 201.19 (2) Personnel policies and procedures

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide routine dental care for one of three residents reviewed for dental concerns (Resident 13).Findings include: Interview and observation of Resident 13 on March 24, 2026, at 10:53 AM revealed Resident 13 had several broken and missing teeth. Resident 13 could not recall the last time she had seen a dentist. Clinical record review revealed the facility admitted Resident 13 on January 15, 2019, the State Medicaid plan was her primary payer source. Further review of Resident 13's clinical record revealed a dental progress note dated October 2, 2024, indicating Resident 13 was not seen on this date due to refusing dental services. Review of Resident 13 care plan-initiated January 15, 2019, revealed Resident 13 is at risk for dental or oral cavity health problems related to abnormal mouth tissue, natural broken teeth with obvious cavities. An intervention added on this date revealed the facility would refer Resident 13 to a dentist for evaluation or…

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

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide recommended pneumococcal immunizations for two of five residents reviewed for immunizations (Residents 6 and 9).Findings include: Clinical record review revealed the facility admitted Resident 9 on April 16, 2024. Documentation in Resident 9's clinical record revealed he received two pneumococcal vaccines prior to his admission (PCV13 and Pneumovax Dose 1). Review of Resident 9's clinical record revealed no evidence that the facility obtained a consent from Resident 9 or his responsible party to administer the updated pneumococcal vaccine. According to the CDC guidance entitled Pneumococcal Vaccine Timing for Adults dated October 2024, Resident 9's pneumococcal vaccinations would not be completed until he received a PCV20 or PCV21 at least one year after PCV13. There was no documented evidence to indicate that the facility offered Resident 9 an updated pneumococcal vaccination. Clinical record review revealed the facility…

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 review and staff interview, it was determined that the facility failed to provide physician ordered treatment for wounds for four of five residents reviewed (Residents CR1, 1, 2, and 4). Findings include: Clinical record review for Resident 1 revealed a physician's order dated July 26, 2025, for the resident to have treatment to a Stage 3 (full thickness skin loss that extends to the fat layer) of the right heel daily cleansing with a normal saline solution (NSS), pat dry, apply skin prep to the wound and leave open to air. There was no evidence this treatment was completed on September 11, and 17, 2025. Closed clinical record review for Resident CR1 revealed a physician's order dated August 25, 2025, for the resident to have a left lateral foot wound cleaned with NSS and have a betadine (antiseptic) soaked cover, pads, and gauze applied and covered with a bandage wrap every three days. The resident also had an order dated August 25, 2025, to receive treatment to venous ulcers (due to poor circulation) on his right foot first toe, left foot third toe, 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 select facility policies, clinical record review, and resident and staff interview, it was determined that the facility failed to provide timely medications to one of five residents reviewed (Resident 3) and failed to obtain and provide medications for one of five residents reviewed (Resident CR1). Findings include: Review of the facility's current policy entitled Medication Administration General Guidelines, revealed it is the facility's policy that medications are administered within 60 minutes of scheduled times, except before or after meal orders, which are administered based on mealtimes. In an interview with Resident 3 on October 1, 2025, at 3:14 PM the resident indicated she sometimes needs to tell staff she needs her medications because they are late. Resident 3 stated she used to get her morning medication closer to 8:00 AM but it has been closer to 10:30 AM at times, and that she believes her medication times were going to change because staff were working on two floors. Review of…

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

Based on a review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier precautions for three of four residents reviewed for infection control concerns (Residents 1, 2, and 3).Findings include: Review of the Center for Medicaid and Medicare Services (CMS) memo entitled, Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms, released by CMS on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices (e.g., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Review of the facility's current policy entitled Enhanced Barrier…

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 clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide activities of daily living care for dependent residents for two of 10 residents reviewed (Residents 5 and 7).Findings include: Interview with Resident 5 on August 14, 2025, at 10:21 AM revealed that no staff provided morning care assistance (e.g., bathing, hygiene, or incontinence care) on this date. Resident 5 stated, they (staff) have done nothing since 4:00 this morning, six hours, no care, no one changed me. Clinical record review for Resident 5 revealed a significant change MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], that assessed Resident 5 as without cognitive deficits (BIMS, Brief Interview for Mental Status, score of 15 out of 15), frequently incontinent of urine and always incontinent of bowel, dependent on staff for toileting, and that he required substantial to maximum assistance…

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 observation and staff interview, it was determined that the facility failed to store, prepare, and serve food in a manner to prevent the potential spread of foodborne illness in the main kitchen and the facility's pantry for three of three nursing units (First, Second, and Third Floor Nursing Unit; Resident 70). Findings include: Review of the 2022 Food and Drug Administration's Food Code revealed that the temperature of the wash solution in spray type ware washers (dishwashers) that use hot water to sanitize may not be less than 160 degrees Fahrenheit and the temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more than 194 degrees Fahrenheit or less than 180 degrees Fahrenheit for a single tank, conveyor, dual temperature machine. Observation of the facility's kitchen on May 13, 2025, at 9:16 AM revealed that staff were actively washing dishes through the facility's high temperature, single tank, conveyor, dual temperature dishwashing machine. The dishwasher was leaking large amounts water out of the bottom of the unit and onto 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 clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medications one of 20 residents (Resident 50). Findings include: Clinical record review for Resident 50 revealed a physician's order dated April 16, 2025, for Metoprolol Succinate ER (for high blood pressure) 200 milligrams (mg) by mouth twice daily for high blood pressure. Hold for systolic blood pressures (when the heart is contracting) less than 100 mmHg (millimeters of mercury) or a heart rate less than 60 beats per minute. Review of Resident 50's April and May 2025, MARs (medication administration record, a form to document medication administration) revealed that staff failed to document either a blood pressure, heart rate, or both on the following dates: April 16, 2025, at 8:00 PM April 17, 2025, at 8:00 PM April 19, 2025, at 8:00 AM and 8:00 PM April 20, 2025, at 8:00 AM and 8:00 PM April 21, 2025, at 8:00 AM and 8:00 PM April 22, 2025, at 8:00 AM and 8:00 PM April 23, 2025, at 8:00 AM and 8:00 PM April 24, 2025,…

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

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase and/or prevent further decrease in range of motion for three of four residents reviewed for range of motion concerns (Residents 13, 46, and 47). Findings include: Interview with Resident 46 on May 13, 2025, at 11:32 AM revealed that her legs are getting stiff. She indicated that she no longer goes to therapy and that she is not getting any exercise done to her legs. Clinical record review of Resident 46's task documentation revealed that staff are to complete passive range of motion (PROM, movement of a joint through range of motion by an external force) to her bilateral lower extremities. The program is set up in the task to be completed two times per day. Further review of Resident 46's task documentation related to her PROM program from April 1, 2025, to May 13, 2025, revealed that not applicable was documented 18 times, and response not required was documented 9…

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 review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for five of six residents reviewed for unnecessary medications (Residents 20. 26, 33, 42, and 45). Findings include: Review of Resident 26's clinical record revealed a progress note dated October 10, 2024, and again on November 20, 2024, indicating that the pharmacist completed a drug regimen review for Resident 26 and to see report for recommendations. There was no documented evidence in Resident 26's clinical record to indicate what the pharmacist recommended or if it was addressed by Resident 26's physician. Review of a pharmacy recommendation dated December 9, 2024, indicated that Resident 26 has been on the same dose of Melatonin (a sleep aid) since 2022. The pharmacist recommended to evaluate the dose or consider changing it to as needed. There was no documented evidence that this recommendation was addressed by Resident 26's physician. Resident 26 remains on the same dose of Melatonin since 2022.…

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 Quality Assurance meeting attendance records and staff interview, it was determined that the facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly with all the required committee members for four of four quarters (May 2024, through May 2025). Findings include: Review of facility's Quality Assurance and Performance Improvement (QAPI) Committee Meeting Attendance Records from May 2024, to May 2025, revealed the facility failed to have an Infection Preventionist in attendance for any of the meetings held in the noted time frame as required to attend at least quarterly. The Nursing Home Administrator indicated in an interview on May 16, 2025, at 12:00 PM that the facility has been without an Infection Preventionist since July 2024, and there was no evidence the Infection Preventionist attended a QAPI meeting in May or June 2024. The facility failed to have all the required QAPI committee members present at least quarterly as required. Cross refer F882, F880 28 Pa Code: 201.18(e )(1)(2) Management

Based on staff interview, it was determined that the facility failed to have a designated Infection Preventionist with the necessary qualifications responsible for the facility's infection prevention and control program. Findings include: Interview with the Nursing Home Administrator on May 13, 2025, at 9:15 AM revealed that the facility's previous Director of Nursing fulfilled the position of infection preventionist until July 2024, at which time she stepped down as the Director of Nursing into another position within the facility and is no longer employed by the facility. The interview indicated that the facility currently does not have an infection preventionist and has not had one since July 2024. Interview with the Nursing Home Administrator on May 15, 2025, at 2:30 PM confirmed the above findings regarding the infection preventionist position. 28 Pa. Code 201.18(b)(1)e)(1)(3)(6) Management 28 Pa. Code 201.19(3) Personnel policies and procedures 28 Pa. Code 211.12(c)(d)(1)(4)(5) Nursing services

Based on select policy review, clinical record review, and staff interview, it was determined that the facility failed to determine a resident's capability to self-administer their medications for one of 20 residents reviewed (Resident 22). Findings include: Clinical record review for Resident 22 revealed the following physician orders: On March 20, 2025, Biofreeze (for pain) 5 percent gel apply to bilateral (both) knees and back topically every day and evening shift for knee and back pain. On May 1, 2025, Resident may keep Biofreeze at bedside. There was no documentation that indicated the facility had assessed Resident 22 for the ability to correctly self-administer their Biofreeze gel. The above information was reviewed during an interview with the Nursing Home Administrator on May 15, 2023, at 2:30 PM. The Nursing Home Administrator confirmed that Resident 22 was not assessed to self-administer medications. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on clinical record review and staff interview, it was determined that the facility failed to implement a resident's right to refuse medications for one of one resident reviewed (Resident 69). Findings include: Clinical record review for Resident 69 revealed that the facility admitted her on October 8, 2024, with a diagnosis of Cerebral Palsy (a disorder that affects muscle tone, movement, and posture due to abnormal brain development before birth). A nursing progress note for Resident 69 dated March 31, 2025, at 1:16 PM indicated that she would not take her evening medications and clamped her mouth shut when offered them. The note indicated that the medications were then given to her through her G-Tube (Gastrostomy tube, a small flexible tube surgically inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications). Further clinical record review revealed that Resident 69's medications were ordered to be given by mouth and there was no order to administer them through her G-Tube. Interview with the Nursing Home Administrator on May 15, 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 clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from medications potentially classified as a chemical restraint for one of six residents reviewed (Resident 46). Findings include: Clinical record review for Resident 46 revealed an order dated February 11, 2025, for Lorazepam (a medication used to treat anxiety) oral tablet 0.5 mg by mouth every six hours as needed for anxiety and agitation. Further clinical record review revealed that Resident 46's order for Lorazepam did not have a 14 day stop date and there was no physician's progress note that provided a rationale for the medication extending past 14 days. Review of Resident 46's medication administration record revealed that she utilized the as needed Lorazepam two times in April 2025, and seven times from May 1-14, 2025. Interview with the Nursing Home Administrator on May 15, 2025, at 10:31 AM confirmed the above noted findings related to Resident 46's Lorazepam. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.10(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 observation, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to care for and monitor a resident's urinary catheter for one of three residents reviewed (Resident 42). Findings include: Observation of Resident 42 on May 13, 2025, at 10:10 AM and May 14, 2025, at 11:44 AM revealed that they were in bed and had a Foley (urine) catheter in place. Clinical record review for Resident 42 revealed that there was a physician's order dated May 2, 2025, for a Foley catheter to gravity. There was no physician's order that identified the size of the Foley catheter, the size of the Foley catheter balloon, or to justify the need for and implementation of Resident 42's catheter. The above information was reviewed with the Nursing Home Administrator during an interview on May 15, 2025, at 2:30 PM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of one resident reviewed (Resident 50). Findings include: Observation of Resident 50's room on May 13, 2025, at 10:06 AM revealed an oxygen concentrator with tubing attached. Observation of and interview with Resident 50 on May 13, 2025, at 11:28 AM revealed that there was an oxygen tank on the back of their wheelchair that was set a 3 liters per minute with oxygen being administered via a NC (nasal canula, tubing to deliver oxygen to the nose). Resident 50 stated that she needed oxygen continuously at 3 liters per minute (LPM) for respiratory concerns/diagnoses. Clinical record review for Resident 50 revealed hospital discharge instructions dated April 15, 2025, that indicated Resident 50 was discharged to the facility on oxygen 3 LPM continuously. Review of Resident 50's physician orders revealed no orders for oxygen usage in the facility. The above information was reviewed with the Nursing Home…

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 staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to enteral feedings, catheter care, or intravenous therapy for two of two employees (Employees 1 and 8). Findings include: A review of the facility's current resident population documentation revealed that the facility has one resident receiving an enteral feeding (alternate form of nutrition administered via a tube), two receiving intra-venous (by vein) therapy, six with an indwelling catheter, and four residents with in-house acquired wounds. A request for nursing staff competencies for Employee 1, registered nurse, and Employee 8, licensed practical nurse, revealed facility staff could not provide any evidence either Employee 1 or Employee 8 had any competency assessments completed to appropriately perform the above care for the residents of the facility. Interview with the Nursing Home Administrator on May 15, 2025, at 2:15 PM revealed there was no evidence of nursing staff competencies available. 28 Pa Code 201.20(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 clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of three residents reviewed (Resident 20). Findings include: Clinical record review for Resident 20 revealed that the facility admitted her on July 19, 2024. Further clinical record review revealed that a diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life), was added to her clinical record on July 29, 2024. A review of Resident 20's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. The findings were reviewed with the Nursing Home Administrator during a meeting on May 16, 2025, at 9:33 AM at which time the Nursing Home Administrator confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of six residents reviewed (Resident 42). Findings include: Clinical record review for Resident 42 revealed a physician's order dated March 21, 2024, for Olanzapine (for schizophrenia, a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) 5 mg (milligrams) by mouth (PO) at bedtime for schizophrenia. Review of Resident 42's clinical documentation revealed no justification for, signs and symptoms, diagnoses of, or documentation, which indicated that Resident 22 had schizophrenia. Review of Resident 42's pharmacy recommendations revealed no documentation where the consultant pharmacist identified that Resident 42's Olanzapine was ordered for schizophrenia without an appropriate diagnosis. The above information was reviewed during an interview with the Nursing Home Administrator on May 15, 2025, at 10:20 AM. 28 Pa.…

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 observation, clinical record review, review of select facility policy and procedures, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 4, 57, and 62). Findings include: The facility's medication error rate was 10.71 percent based on 28 medication opportunities with three medication errors. The policy entitled Nasal Administration, dated September 27, 2024, indicates that nursing staff are to have the resident gently blow their nose prior to administration. During administration, nursing staff are to press a finger to the nostril not being used for administration. Observation of a medication administration pass on May 13, 2025, at 8:35 AM revealed Employee 1, licensed practical nurse, preparing to administer a saline nasal solution (helps with dry nasal passages) nose spray to Resident 57. Employee 1 administered one spray of the saline nasal spray to each of Resident 57's nostrils. Employee 1 did not have Resident 57 blow her nose or press close the opposite nostril during the administration 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 observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier precautions for one of 24 residents reviewed (Residents 52). Findings included: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Review of the facility's current policy entitled Enhanced Barrier Precautions, revealed it is the facility's policy to use EBP in addition to Standard…

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 review and staff interview, it was determined that the facility failed to offer and administer a COVID immunization for one of five residents reviewed for immunizations (Resident 69). Findings include: Clinical record review revealed the facility admitted Resident 69 on October 8, 2024. Review of Resident 69's clinical record revealed no documentation of any COVID-19 vaccines. Review of Resident 69's COVID 19 vaccine consent form date October 8, 2024, revealed a signed consent requesting the facility administer the current CDC recommended COVID vaccine. There was no additional information in Resident 69's clinical record that the facility offered or administered Resident 69 a COVID immunization since admission October 8, 2024. Interview with the Nursing Home Administrator on May 16, 2025, at 10:35 AM confirmed these findings. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of facility documents, and resident and staff interview, it was determined that the facility failed to accurately report an incident as an allegation of neglect for one of four residents reviewed (Resident 2). Findings include: Review of a facility reported incident to the State event reporting system dated March 26, 2025, revealed facility staff reported Resident 2 as requiring transfer to the hospital due to an accident /injury on March 26, 2025, at 10:45 AM. The incident indicated that Resident 2 was found lying on the floor in her room with her head on the floor between the bed and nightstand. The resident was reported as having pain to the right knee and right arm, and a hematoma (bruise, a collection of blood that pools outside of a blood vessel) was noted by her right eye. The resident was reported as being sent to the emergency room for evaluation. The incident report was rejected by the State on March 27, 2025, requesting more information regarding if staff followed care plan interventions for Resident 2 at the time the incident…

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 clinical record review and resident and staff interview, it was determined the facility failed to ensure that a resident who is dependent on staff for toileting, toileting hygiene, and mobility in bed, receives the appropriate treatment and services to meet the professional standards of care to the extent possible for one of six residents reviewed (Resident 4). Findings include: In an interview with Resident 4 on August 29, 2024, at 10:24 AM the resident was observed lying in bed stating she was waiting to go get a shower. Resident 4 stated, It takes two people to change me and sometimes they wait until my shower in the morning to change me, but I have been lying here wet, and I am soggy. Resident 4 indicated she last had her brief changed at 4:00 AM. A slight urine odor was present near the resident and as the resident had her covers pulled back, with her brief exposed, the brief appeared wet and full. Resident 4 stated she has had a diaper rash for two months. Resident 4 also indicated she was 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 observation and staff and resident interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to maintain a clean and orderly environment two of three nursing units (A and B unit, C unit; Residents 3, 4, 5, 6, 7, and 8). Findings include: Observation of Resident 3's room on August 6, 2024, at 8:18 AM revealed a two light bulb fixture recessed into the ceiling of the bathroom, which also served as the exhaust fan. The unit contained a thick coating of dust covering the interior portion of the unit visible when looking up at the light. A rusty metal washer was lying on the floor to the right sink side of the toilet base, and an additional washer was observed on the base of the toilet next to it. A large pile of black and brown debris was scattered on the base of the toilet covering where the washers were located. An observation of Resident 6's bathroom on August 6, 2024, at 8:27 AM revealed peeling wallpaper along the walls where the wallpaper met the cove base. An observation of Resident 5's room on August 6, 2024, at 8:38…

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 observation and staff interview, it was determined that the facility failed to store food in accordance with professional standards for food service safety and sanitation in the facility's main kitchen. Findings include: An observation of the facility's main kitchen on April 7, 2024, at 8:38 AM revealed the following: A coffee station was observed with cabinets below the coffee maker with sliding doors. The tracks of the doors were filled with dried food, debris, and ground coffee. A household refrigerator located in the preparation area was observed with a dried white substance covering the lower interior shelf of the refrigerator and dried liquid spills on the interior door. A sliding window and wall behind a preparation table located beside the refrigerator noted above was covered with dried food splatter. A piece of equipment on a cart beside the table covered in a garbage bag was also observed with dried food splatter on the exterior of the garbage bag. A cart the piece of equipment was sitting on was covered in dust and debris as well as a dolly the cart sat on top…

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 and resident interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to maintain a clean and orderly environment on three of three nursing units (A and B Nursing Unit, D and E Nursing Unit, C Nursing Unit; Residents 7, 27, 43, 44, 79, 84, 89, 91, 97, and 153). Findings include: Observation of the facility's B hall nursing unit on April 8, 2024, at 8:58 AM revealed the following environmental concerns: At the end of the B hall nursing unit, the wallpaper was stained to the right of the heating and air conditioning unit. The wall outside Resident 84's room had peeling, stained, and cut wallpaper. Resident 84's room was missing a closet door. Resident 89's room was missing one of the closet doors. One handle fixture of the closet door was loose. The plastic protective cover on the lower half of the room doorway was broken and jagged. Observation of the facility's E hall nursing unit on April 8, 2024, at 11:30 AM, revealed the following environmental concerns: The closet door bottom brackets were…

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 review and staff interview, it was determined that the facility failed to provide timely assessment and implement interventions to promote acceptable parameters of nutritional status for four of seven residents reviewed for nutritional concerns (Residents 46, 59, 86, and 91). Findings include: Review of Resident 46's clinical record revealed that the facility admitted him on March 18, 2024. Resident 46 was admitted to the facility with a diagnosis of malnutrition and needing a feeding tube for nutrition. There was no documented evidence in Resident 46's clinical record to indicate that an initial comprehensive dietary assessment was completed. A Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated March 25, 2024, indicated that the facility assessed him as being at nutritional risk and that the facility would proceed to develop a care plan regarding his risk for weight loss. There was no documented evidence in Resident 46's clinical record to indicate that the facility developed a potential for weight…

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 review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of five residents reviewed (Resident 13). Findings include: Clinical record review for Resident 13 revealed a physician's order dated November 1, 2023, and discontinued on March 6, 2024, for Ativan (for anxiety) 1 milligram (mg) by mouth (PO) twice daily (BID) as needed (PRN) for 60 days. On March 16, 2024, Resident 13's physician reordered the Ativan 1 mg PO BID PRN for anxiety for another 60 days. Review of Resident 13's February, March, and April 2024 MARs (medication administration record, a form to document medication administration) revealed that there was no documentation that staff attempted non-medicinal interventions prior to administration of her PRN Ativan for 24 of the 25 administrations in February 2024, for 29 of the 36 administrations in March 2024, and for 9 of the 10 administrations in April 2024. The surveyor reviewed the above information for Resident 13 during an…

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 review and staff interview, it was determined that the facility failed to determine a resident's wishes regarding an advance directive for one of 10 residents reviewed (Resident 27). Findings include: Clinical record review for Resident 27 revealed that the facility admitted her on March 6, 2024, with a diagnosis of a left femoral fracture and end stage renal disease. Clinical record review revealed her advance directive to be DNR (Do Not Resuscitate, a medical order that instructs health care providers not to intervene if a patient stops breathing or if their heart stops beating). A Medical Practitioner Note (Physician/ Nurse practitioner) dated March 7, 2024, at 10:28 PM revealed that Resident 27 was severely lethargic and fatigued. Her neurological assessment revealed that she was alert, awake, and oriented to person only. The note further indicated that Resident 27 desired to be a DNR based on her advance directive. Interview with the Nursing Home Administrator and Director of Nursing (DON) on April 9, 2024, at 2:12 PM revealed that they obtained…

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 review and staff interview, it was determined that the facility failed to provide the correct required notification to a resident whose payment coverage changed for two of five residents reviewed (Residents 34 and 89). Findings include: A review of the Form Instructions Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 revealed that examples of the common reasons why an extended care stay, or services may not be covered under Medicare might include the beneficiary no longer requires daily skilled care for a medical condition but wants to continue residing in the skilled nursing facility (SNF). The SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. In the blank that follows Beginning on ., the skilled nursing facility enters the date on which the beneficiary may be responsible for paying for care that Medicare is not expected to cover. The beneficiary selects an option box to indicate a desire to continue to receive the care or not to continue to receive…

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 clinical record review and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to maintain the highest practicable care for one of three residents reviewed (Resident 81). Findings Include: Clinical record review for Resident 81 revealed that he was admitted to the facility on [DATE], and his primary language was Spanish. He was also able to speak in broken English (you speak English with difficulty or with a lot of mistakes). Interview with the Nursing Home Administrator and Director of Nursing on April 9, 2024, at 2:10 PM revealed that staff communicate with Resident 81 through one employee, a licensed practical nurse, that speaks Spanish, and some staff have interpreter applications on their phones. A Medical Practitioner (Physician or Nurse Practitioner) progress note dated March 4, 2023, at 2:33 PM revealed that Resident 81 solely speaks Spanish, but can communicate through movements such as head nods. A Social Determinant 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 clinical record review and staff interview, it was determined that the facility failed to provide treatment to improve hearing for one of three residents reviewed (Resident 81). Findings include: Clinical record review for Resident 81 revealed an audiologist (a health care professional that assesses and manages disorders of hearing) progress note from an outside provider dated March 21, 2024, at 12:20 PM that indicated his left ear was impacted with cerumen (ear wax). The note further indicated that it should be removed as soon as possible by the facility if the resident allows. The facility should follow their protocol for cerumen removal with Debrox (a medication used to treat wax build-up) as ordered by the facility physician. Resident 81 should return for a hearing exam following cerumen removal. Clinical record review for Resident 81 revealed no evidence that the Debrox treatment to his ear was ordered or done. Interview with the Nursing Home Administrator on April 9, 2024, at 2:10 PM confirmed that the audiologist recommendations for Resident 81, were never reviewed…

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 review and staff interview, it was determined that the facility failed to evaluate a pressure ulcer to prevent decline and promote healing for one of two residents reviewed (Residents 27). Findings include: Clinical record review for Resident 27 revealed that the facility admitted her on March 6, 2024, with a closed wound to her left heel. Review of Resident 27's skin and wound evaluation dated March 7, 2024, revealed that she had an abrasion that was present on admission and measured 2.5 centimeters (cm) x 2.0 cm with no depth. The wound bed was 100 percent covered with epithelial (a type of tissue that covers many surfaces on the inside and outside of your body). There was no slough (yellowish/white material noted on a wound bed) or eschar (dead tissue) present, and there was no drainage. It was a foam dressing and there was no additional care noted on the evaluation. An admission MDS (Minimum Data Set, an assessment completed at intervals by the facility to determine care needs) date March 13, 2024, revealed that Resident 27 did not have any pressure…

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 review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations timely and implemented accepted recommendations timely for two of five residents reviewed (Residents 50 and 80). Findings include: Clinical record review for Resident 50 revealed a consultant pharmacist recommendation dated February 6, 2024, for the initiation of Vitamin D3 for the resident. The recommendation was noted as accepted by the physician and signed on February 25, 2024, by the physician. Further record review for Resident 50 revealed the resident did not receive a physician's order for the Vitamin D3 until March 6, 2024, 10 days later. Clinical record review for Resident 80 revealed a consultant pharmacist recommendation dated October 13, 2023, to check a serum Vitamin D level on the resident due to a recent fall. The recommendation was reviewed by the physician until November 27, 2023, greater than 30 days from the date of the recommendation. The physician did accept the recommendation 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 staff interview, it was determined that the facility failed to employ a qualified registered dietitian, in the absence of a full time certified dietary manager. Findings include: Interview with the Administrator on April 7, 2024, at 2:00 PM revealed that the facility has not had a qualified dietitian either full time, part time, or on a consultant basis since March 8, 2024. It was also confirmed that the facility does not have a certified dietary manager. 28 Pa Code 201.18(e)(6) Management

Based on review of facility staff education records and staff interview, it was determined that the facility failed to ensure that all nurse aide staff completed a minimum of 12 hours of in-service education training each year for two of four nurse aides reviewed (Employees 2 and 3). Findings include: During an interview with the Nursing Home Administrator (NHA) and Employee 6, human resources director, scheduler, and payroll, on April 10, 2024, at 9:30 AM the surveyor requested evidence of annual in-service education for Employee 2, nurse aide, hired January 25, 2022, and Employee 3, nurse aide, hired February 2, 2016. Interview with the NHA and Employee 6 on April 10, 2024, at 10:00 AM confirmed that Employee 2 only completed 6.26 hours and Employee 3 only completed 3.01 hours of the required 12 hours of annual in-service education, which included dementia training, abuse prevention training, and any areas of weakness or resident special care needs in the past year. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.20(a)(d) Staff development 28 Pa. Code 211.12(c) Nursing services

Based on clinical record review, and staff interview, it was determined that the facility failed to secure transportation for outside services for one of two residents reviewed for transportation needs (Resident 1). Findings include: Clinical record review for Resident 1 revealed the resident has a diagnosis of hypercalcemia, (a condition in which the calcium level in the blood become too high), and hyperparathyroidism, (a condition that develops from too much activity in one or more parathyroid glands which boost the level of calcium in the bloodstream when needed), and these conditions were managed by the resident's endocrinologist. A review of Resident 1's appointments with the endocrinology revealed the resident met with the endocrinologist on March 27, 2023, June 27, 2023, and was scheduled to meet again on August 28, 2023. A progress note for Resident 1 dated August 28, 2023, at 9:18 AM noted transportation was unable to take the resident to the appointment with endocrinology and it was rescheduled for August 30, 2023. A progress note for Resident 1 dated August 29, 2023, 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 clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding the implementation of physician-ordered recommendations regarding an oral medication for one of two residents reviewed (Resident 1). Findings include: Clinical record review for Resident 1 revealed the resident has a diagnosis of hypercalcemia, (a condition in which the calcium level in the blood becomes too high), and hyperparathyroidism, (a condition that develops from too much activity in one or more parathyroid glands which boost the level of calcium in the bloodstream when needed), and these conditions were managed by the resident's endocrinologist. Further clinical record review for Resident 1 revealed a facility consultation form for Resident 1 from endocrinology dated March 27, 2023, noting the diagnosis of hypercalcemia, and hyperparathyroidism with recommendations to start Sensipar (cinacalcet, a medication used to treat high levels of calcium in the blood), 15 milligrams (mg) daily, and the resident was to return in three…

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 clinical record review and resident and staff interview, it was determined that the facility failed to ensure that medically related social services were provided to one of two residents reviewed (Resident 2). Findings include: In an interview with Resident 2 on [DATE], at 11:15 AM in the resident's room, Resident 2 stated she had resided in the room next door prior to the current room, and her roommate died. Resident 2 continued to say, She wasn't even that old, we had been talking, it was in the middle of the night, and I was up due to still having pain, then she was just gone. Resident 2 stated it was scary for her, she had never been in a nursing home, and after they all left, I knew she was gone. They pulled the curtain, and she was left in the room with her until later in the morning, when they came to take her out. Resident 2 indicated she was never approached by any staff to ask if she wanted to leave the room while her deceased roommate remained on the other side of the curtain, and again…

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 review, review of facility documentation, and staff interview, it was determined that the facility failed to obtain physician ordered medications for one of six residents reviewed (Resident CR1). Findings include: Review of the facility's pharmacy schedule revealed that on Monday through Friday, orders need to be received by 7:00 PM for a delivery departure at 8:00 PM. For Saturday, orders need to be received by 4:00 PM for a delivery departure at 5:00 PM. If a medication is needed prior to the next scheduled delivery and is not in the emergency/back-up supply, please follow your regular process to submit the order, then to request the medications STAT (immediately). Closed clinical record review for Resident CR1 revealed that on Friday, September 1, 2023, at 3:48 PM the facility admitted him with diagnoses of atrial fibrillation (irregular heart rhythm), COPD (chronic obstructive pulmonary disease, restriction of the airways causing breathing difficulty), adult failure to thrive (weight loss, poor appetite/nutrition), schizoaffective disorder (a mental…

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.