Heritage Ridge Senior Living At Johnstown

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a peripherally inserted central catheter (PICC- a thin, flexible tube that is inserted into a vein in the upper arm) was flushed according to facility policy for one of 33 residents reviewed (Resident 9). Findings include:The facility's policy regarding flushing and locking peripheral and midline catheters dated August 25, 2025, indicated that the purpose of the procedure was to maintain catheter patency, to prevent mixing of incompatible medications and solutions, and to ensure the entire dose of a solution or medication is administered into the venous system. For short and long peripheral and midline catheters used for intermittent infusions, flush (procedure involving the injection of saline into a catheter using a small syringe to clear or maintain patency) the catheter and aspirate for blood return prior to each infusion and at least every 24 hours to assess catheter function. Lock (a peripheral intravenous catheter is capped off and filled…

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 obtain laboratory studies as ordered by the physician for one of 33 residents reviewed (Resident 13).Findings include: The facility's policy regarding laboratory services and reporting, dated August 25, 2025, revealed that the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process the test requisitions and arrange for tests, the laboratory, diagnostic radiology provider, or other testing source will report test results to the facility.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated November 3, 2025, revealed that the resident was cognitively impaired, was dependent on staff for daily care needs and was always incontinent of bladder.Physician's orders for Resident 13, dated November 28, 2025, included an order for staff to obtain a urine culture and sensitivity (a diagnostic test for urinary…

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

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to serve palatable food that was at appropriate temperatures. Findings include: The facility's policy regarding food temperatures and point of service, dated August 25, 2025, indicated that hot foods would be held at temperatures of 135 degrees or above. Best efforts would be made to present hot food hot and cold foods cold at point of service by using thermal lids and bases and heated or chilled plates. Interview with Resident 3 on January 12, 2026, at 11:01 a.m. revealed that the food is always cold, the bread is stale, and it doesn't taste good. Interview with Resident 6 on January 12, 2026, at 11:32 a.m. revealed that the food is like cold dog food. Observations of the kitchen's lunch meal tray line on January 14, 2025, revealed that it began at 12:01 p.m. and included spaghetti, mixed vegetables, garlic bread, side salad, coffee and juice. The last tray was placed on the cart at 12:12 p.m. The cart left the kitchen and arrived on the unit at 12:17 p.m., and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 33 residents reviewed (Residents 4 and 41). Findings include:The RAI User's Manual, dated October 2025, indicated that Section O0110K1B Hospice care (a specialized form of end-of-life care that provides comfort, support, and medical assistance to terminally ill patients and their families) was to be checked to indicate if the resident was receiving hospice services while a resident. Physician's orders for Resident 4 dated May 14, 2025, include for the resident to be admitted to Hospice care. A quarterly MDS assessment for Resident 4, dated November 12, 2025, revealed that Section O0110K1B was not checked, indicating that the resident did not receive hospice service during the seven-day look-back assessment period. Interview with the Director of Nursing on January 13, 2026, at 11:12 p.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to discard a multi-use vial of Tubersol (solution used to detect tuberculosis infection) and an expired multidose medication for one resident (Resident 10) in one of one medication rooms reviewed. Findings include: The facility's policy regarding medication administration, dated [DATE], indicated medications are administered in a safe and timely manner and as prescribed. The expiration date on the medication label is checked prior to administration. When opening a multidose medication the opened date is recorded on the container. Manufacturer's instructions for Tubersol, dated [DATE], indicated that a multi-dose vial of Tubersol solution should be discarded 30 days after it is opened. Physician's orders for Resident 10, dated [DATE], included an order for the resident to receive 20 ml (milliliters) for a total of 40 mg(milligrams) of Omeprazole Oral Solution (used to treat gastroesophageal reflux…

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 maintain clinical records that were complete and accurately documented for one of 33 residents reviewed (Resident 42).Findings include: The facility's policy regarding medication administration, dated August 25, 2025, indicated that after medication administration, the facility staff should take all measures required by facility policy and applicable law, including but not limited to documenting necessary medication administration/treatment information (when the medication was given, prn/as needed medications) on appropriate forms. Document the administration of controlled substances in accordance with applicable law. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated November 14, 2025, indicated the resident was cognitively impaired, required assistance for daily care needs, took opioid medications, and had diagnoses that included heart failure. 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.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending February 12, 2025, 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 January 14, 2026, identified repeated deficiencies related to accuracy of assessment, failure to provide quality of care, failure to provide proper catheter care, failure to store and label residents medications properly, and failure to ensure food was palatable and served at the proper temperature. The facility's plan 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 neurological assessments including vital signs and neurological checks were completed following an unwitnessed fall for three of seven residents reviewed (Residents 1, 2, and 6).Findings include:The facility's policy for neurological assessments, dated November 4, 2024, indicated that neurological assessments are indicated upon physician's orders; following an unwitnessed fall; subsequent to a fall or other accident/injury involving head trauma; and when indicated by resident condition. When assessing neurological status, always include frequent vital signs. Perform neurological checks with the frequency as ordered or per fall protocol. The facility's neurological flow sheet indicated that vital signs and neurological checks were to be completed every 15 minutes for one hour, then every 30 minutes for one hour, then every hour for four hours, then every four hours for 24 hours.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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications (medications that affect the mind, emotions and behavior), by failing to ensure that non-pharmacological (non-medication) behavioral interventions (individualized, non-pharmacological approaches to care), were attempted prior to the administration of as needed antianxiety medications (psychotropic medication used to treat anxiety) for one of seven residents reviewed (Resident 6).Findings include:The facility's policy regarding psychotropic medication use, dated November 4, 2024, indicated that non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated April 24, 2025, revealed that the resident was cognitively…

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 complete a thorough investigation for an incident that occurred for one of four residents reviewed (Resident 2). Findings include: A facility policy for incident and accident reports, dated January 20, 2025, revealed that the accidents or incidents involving residents, employees, visitors and vendors, occurring on our premises shall be investigated and reported to the administrator. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 3, 2025, revealed that the resident was cognitively intact, required extensive assistance with daily care needs, and had a diagnosis of dementia. Interview with the Social Worker on April 17, 2025, at 10:35 a.m. revealed an incident in March 2025 when Resident 2's spouse came to the facility, took Resident 2 out of the building, and attempted to put her in his vehicle to take her home. He made threats towards staff and the police were called. 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 follow physician's orders for care and treatment for five of 29 residents reviewed (Resident 1, 24, 26, 37, 38). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 8, 2024, revealed that the resident was cognitively impaired, required assistance with care needs, was frequently incontinent of bowel, and had a diagnosis of dementia. Physician's orders for Resident 1, dated July 6, 2024, included an order for the resident to receive 30 milliliters (ml) of Milk of Magnesia as needed for constipation if no bowel movements in three days, which as to be administered on the 7:00 a.m. to 3:00 p.m. shift on the first medication pass. Review of Resident 1's bowel record for February 2025 revealed no documented evidence that the resident moved his bowels from February 1 through February 4, 2025, for a total of four days. Review of Resident 1's Medication Administration Record…

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 monthly pharmacy medication reviews were completed for seven of 29 residents reviewed (Residents 16, 21, 23, 26, 33, 38, 50). Findings include: The facility policy regarding pharmacy services, dated January 20, 2025, indicated that the consultant pharmacist will provide a documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines; provide appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated; and provide the facility with written or electronic reports and recommendations related to all aspects of medication and pharmaceutical services review. Review of the clinical records for Residents 16,…

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

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to serve palatable food that was at appropriate temperatures. Findings include: The facility's policy regarding food temperatures and point of service, dated January 20, 2025, indicated that hot foods would be held at temperatures of 135 degrees or above. Best efforts would be made to present hot food hot and cold foods cold at point of service by using thermal lids and bases, heated or chilled plates, and thermal pellets as necessary. Observations of the kitchen's lunch meal tray line on February 10, 2025, revealed that it began at 12:01 p.m. and included barbecued ribs, homestyle baked beans, corn on the cob, and watermelon. The last tray was placed on the cart at 12:14 p.m. The cart left the kitchen and arrived on the unit at 12:17 p.m., and the last tray was removed from the cart and served at 12:27 p.m. The test tray was removed from the cart at 12:42 p.m. The barbecued rib was 114 degrees Fahrenheit (F) and tasted cold and was not palatable, the baked beans 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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or resident representative had an opportunity to develop an advance directive (instructions regarding the provision of health care when the resident is incapacitated) or assist in formulating an advance directive for one of 29 residents reviewed (Resident 33). Findings include: The facility policy regarding advance directives, dated January 20, 2025, indicated that upon admission, the resident or resident representative will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident or resident representative indicates that he or she has not established advance directives, the healthcare center staff will offer assistance in establishing advance directives. The resident or resident representative will be given the option to accept or decline the assistance, and care will not be contingent on…

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

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's attending physician was notified about medication refusals of insulin and requests to speak to the physician for one of 29 residents reviewed (Resident 26). Findings include: An admission MDS assessment for Resident 26, dated January 14, 2025, revealed that the resident was cognitively intact, required assistance with personal care needs, and had diagnoses that included stroke and diabetes. Physician's orders for Resident 26, dated January 7, 2025, included an order for the resident to receive six units of insulin lispro (fast-acting insulin to treat high blood sugar) daily with lunch and dinner. Review of the MAR for January 2025 and February 2025 revealed that the resident refused her dinnertime dose on January 21, 27, and 30, and February 4 and 8, 2025. Physician's orders for Resident 26, dated January 8, 2025, included an order for the resident to receive 18 units of insulin lispro daily with breakfast. Review of the MAR, dated January 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 reviews and staff interviews, it was determined that the facility failed to notify the resident and/or resident's representative and the ombudsman in writing of the transfer and reason for hospitalization for four of 29 residents reviewed (Residents 13, 23, 33, 37). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated November 26, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnosis that included heart failure and diabetes. A nurse's note for Resident 13, dated May 13, 2024, at 6:30 p.m., revealed that the resident was observed lying on the floor in his room with bleeding observed from above his left eyebrow and above his left ear. The resident was transferred to the emergency room for evaluation and treatment. There was no documented evidence that a written notice of Resident 13's transfer to the hospital was provided to the resident and/or resident representative and the ombudsman…

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 provide a written notice of the facility's bed-hold policy to the resident and/or the resident's representative at the time of a transfer for four of 29 residents reviewed (Residents 13, 23, 33, 37). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated November 26, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnosis that included heart failure and diabetes. A nurse's note for Resident 13, dated May 13, 2024, at 6:30 p.m., revealed that the resident was observed lying on the floor in his room with bleeding observed from above his left eyebrow and above his left ear. The resident was transferred to the emergency room for evaluation and treatment. There was no documented evidence that a bed-hold notice was provided to Resident 13 or his responsible party. A quarterly MDS assessment for Resident 23,…

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 six of 29 residents reviewed (Residents 9, 17, 21, 26, 37, 42). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, revealed that N0415E anticoagulant (medications used as a blood thinner) was to be coded (1) is taking, if the resident received an anticoagulant medication during the seven-day assessment period. A quarterly MDS assessment for Resident 9, dated November 13, 2024, revealed that Section N0415E was not coded (1), which indicated that the resident did not receive an anticoagulant during the seven-day assessment period. Physician's order for Resident 9, dated June 22, 2024, included an order for the resident to receive 2.5 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 facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that resident-centered care plans were developed and implemented for three of 29 residents reviewed (Residents 7, 16, 33). Findings include: The facility's policy regarding care plans, dated January 20, 2025, indicated that the comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated November 13, 2024, revealed that the resident was cognitively intact, required assistance with care needs, received an antibiotic, anticoagulant (blood thinner), diuretic (a medication used to treat fluid build-up), and insulin, and had diagnoses that…

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

Based on review of 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 29 residents reviewed (Residents 9, 13). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated November 18, 2024, revealed that the resident was understood, could understand others, had a Brief Interview for Mental Status (BIMS -a structured cognitive interview) of 15 indicating that the resident was cognitively intact, required substantial to max assistance for showering and bathing, and had diagnoses that included congestive heart failure (CHF) and a history of falls. A care plan for self care performance deficit, dated June 21, 2024, indicated that the resident prefers showers twice a week, but may refuse. A care plan for the resident, dated June 24, 2024, revealed that the resident had the potential for actual skin impairment due to ichthyosis vulgaris (a common,…

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

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that assistance devices to prevent accidents or injury were in place for three of 29 residents reviewed (Residents 13, 17, 24) Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated November 26, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included heart failure and diabetes. Physician's orders for Resident 13, dated May 29, 2024, included an order for the resident to have a chair alarm to his wheelchair at all times. A nurse's note for Resident 13, dated July 20, 2024, at 2:00 p.m., revealed that the resident had fallen in his bathroom. The resident reported that he was trying to ambulate from his wheelchair to the bathroom. The chair pad alarm was not present on his wheelchair. A facility incident investigation, dated July 20, 2025, indicated that the resident's chair alarm was not in…

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

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling urinary catheters (a flexible catheter used to drain urine from the bladder into a drainage collection bag) and nephrostomy tubes (thin, flexible tube inserted into the kidney through the skin to drain urine directly into a collection bag) for two of 29 residents reviewed (Residents 1, 37). Findings include: A facility policy related to catheter care, dated January 20, 2025, indicated that the catheter tubing and drainage bag are kept off the floor and to observe urine level for noticeable increases or decrease. If the level stays the same, or increases rapidly, report it to the physician or supervisor. Follow the facility procedure for measuring and documenting input and output. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 8, 2024, revealed that the resident was cognitively…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 29 residents reviewed (Resident 26). Findings include: The facility's policy for medication administration, dated January 20, 2025, indicated that the individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next one. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 26, dated January 14, 2025, revealed that the resident was cognitively intact, required assistance with personal care needs, and had diagnoses that included stroke and diabetes. Physician's orders for Resident 26, dated January 7, 2025; January 22, 2025; and February 5, 2025, included an order for the resident to receive 25 milligrams (mg) of Tramadol (a narcotic pain medication) every…

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, clinical records, and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 29 residents reviewed (Resident 21). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 21, dated November 27, 2024, indicated that the resident was cognitively intact, required assistance from staff for personal hygiene needs, and had diagnosis that included right femur (thigh bone) fracture. A nurse's note for Resident 21, dated October 2, 2024, at 9:42 p.m. revealed that orders were received to continue administering 2.5 milligrams (mg) of Coumadin (blood thinner) every Monday, Wednesday, and Friday, and 2 mg of Coumadin every Tuesday, Thursday, Saturday, and Sunday. Review of the Medication Administration Record (MAR) for Resident 21, dated October 2024, revealed no documented evidence that Coumadin was administered on October 2 through October 15, 2024. Interview with the Director of Nursing on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label a multi-use vial of Aplisol in one of one medication room reviewed. Findings include: The facility's policy regarding medication labeling and storage, dated [DATE], indicated medications and biologicals are stored in a safe, secure, and orderly manner. Nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary method. Manufacturer's directions for use of Aplisol (tuberculin purified protein derivative), dated [DATE], indicated that the vials in use more than 30 days should be discarded due to possible oxidation and degradation, which may affect potency. Observations in the facility's medication room refrigerator in the main medication room on February 12, 2025, at 1:29 p.m. revealed one multi-use vial of Aplisol that was open and undated. Interview with Licenced Practical Nurse 2 at the time of the observation confirmed…

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 obtain laboratory services as ordered by the physician for one of 29 residents reviewed (Resident 1). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 8, 2024, revealed that the resident was cognitively impaired, required assistance with care needs, was frequently incontinent of bowel, and had a diagnosis of dementia. A nursing note for Resident 1, dated January 20, 2025, at 6:38 p.m., revealed that the resident had a large bowel movement with red staining noted to his sheets around the stool. Physician's orders for Resident 1, dated January 20, 2025, included an order to obtain three stool samples for immuno-fecal occult (hidden) blood with instructions to record each collection in the resident's electronic health record and notify the physician if positive. A nursing note for Resident 1, dated January 21, 2025, at 9:29 a.m., revealed that the resident's first fecal occult…

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

Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending February 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 February 12, 2025, identified repeated deficiencies related to a failure to develop and implement comprehensive care plans, failure to update/revise care plans, failure to provide quality of care, failure to provide a safe environment that is free of accident hazards, failure to maintain compliance with the regulation regarding complete and accurate accounting 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 observations and staff interviews, it was determined that the facility failed to use proper infection control practices to reduce the spread of infections and prevent cross-contamination for one of 29 residents reviewed (Resident 1). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 8, 2024, revealed that the resident was cognitively impaired, required assistance with care needs, had an indwelling urinary catheter (a flexible catheter used to drain urine from the bladder into a drainage collection bag), had diagnoses that included neurogenic bladder (bladder lacks control due to nerve or muscle problems), and had a urinary tract infection in the last 30 days. A care plan for the resident, dated June 25, 2024, revealed that the resident had an indwelling urinary catheter. Physician's orders for Resident 1, dated December 30, 2024, included an order for an indwelling foley catheter to straight drainage, ensure catheter tubing and bag are secured to bed frame and not…

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

Based on review of facility policies and written menus, as well as observations and staff and resident interviews, it was determined that the facility failed to ensure that dietary staff served the planned portion sizes and had condiments available per resident preference. Findings include: A facility policy related to menus, dated January 20, 2025, indicated that menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. Deviations from posted menus are recorded (including the reason for the substitution and/or deviation) and archived. Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal. If a food group is missing from a resident's daily diet, the resident is provided an alternative means of meeting his or her nutritional needs. The facility's written menu for the breakfast meal on January 23, 2025, revealed that the residents were to receive two pancakes each, six ounces of breakfast grits, two slices 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, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to store food under sanitary conditions, failing to ensure that food was served under sanitary conditions, and by failing to properly label and date refrigerated and frozen foods. Findings include: The facility's policy regarding food labeling and dating, dated February 23, 2024, revealed that leftovers and open foods shall be clearly labeled with the date the food item is to be discarded. Food items to be labeled and dated included items prepared in house and food items that are opened and stored for later use. The facility's policy for cleaning standards, dated February 23, 2024, revealed that food contact surfaces, non-food contact surfaces, equipment, pans, and utensils must be kept clean at all times. This includes but not limited to free of grease deposits, food residue, dust, and other soil accumulation/debris. Observations in the facility's kitchen…

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 information provided by the facility, as well as observations and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures. Findings include: The facility's policy regarding food temperatures, dated February 23, 2024, revealed that the temperatures of foods shall be recorded before being served from the steam table. Hot foods will be held at temperatures 135 degrees or above and cold foods will be held at 41 degrees or below prior to serving to maintain food safety. Best efforts will be made to present hot foods hot and cold foods cold at the point of service by using various temperature retention service ware such as thermal lids and bases, heated or chilled plates and thermal pellets as necessary. Observations of the lunch meal service in the main kitchen on December 18, 2024, revealed that the first B hallway cart containing a test tray left the main kitchen at 12:15 p.m. and arrived on B hallway at 12:17 p.m. Trays were passed to the residents that were in their rooms starting at 12:17…

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 written menus, as well as observations and staff interviews, it was determined that the facility failed to ensure that dietary staff served the planned portion sizes. Findings include: The facility's written menu for the lunch meal on October 24, 2024, revealed that the residents were to receive four ounces of steak fries and four ounces of homemade coleslaw. Observations during the lunch meal in the main kitchen on October 24, 2024, at 12:08 p.m. revealed that Dietary [NAME] 1 was preparing plates for residents who were to receive their meal trays in the skilled main dining room and their rooms. Dietary [NAME] 1 would reach into a bin on the steam table with a gloved hand and grab a hand full of steak fries and then place them on the plates. Then using metal tongs, she would reach in a metal pan and obtain the homemade coleslaw and place the homemade coleslaw on the plate. She then was given metal tongs to obtain the steak fries. She would reach in the bin in the steam table and obtain the steak fries and then place them on a plate. There were times that Dietary…

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

Based on review of facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to review and revise care plans for two of five residents reviewed (Residents 2, 4). Findings include: The facility's policy regarding care plans, dated February 22, 2024, indicated that the comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 9, 2024, indicated that the resident was cognitively impaired, required assistance with care needs, had a weight gain, and had diagnoses that included anemia (blood disorder in which the blood has a reduced ability to carry oxygen) and gastroesophageal reflux disorder (a digestive…

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, as well as interviews with facility staff and residents, it was determined that the facility failed to ensure that dentures were in place to maintain the ability to chew foods for one of five residents reviewed (Resident 4). Findings include: A quarterly MDS assessment for Resident 4, dated August 16, 2024, revealed that the resident was cognitively impaired, was usually understood and usually able to understand others, required assistance with some care needs, and had a diagnosis of that included dysphagia (difficulty swallowing). Physician's orders for Resident 4, dated August 28, 2024, included an order for the resident to receive a no added salt, regular texture diet. Observations on September 18, 2024, at 9:07 a.m. revealed that Resident 4 was sitting at the side of her bed and had eaten all the food on her breakfast tray. Her tray ticket indicated that she received French toast and sausage. She indicated that her food was good, but she had to gum it. Observations at that time indicated that the resident did not have teeth and did not have dentures in her…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to to ensure that food items stored in the nutrition room were labeled, dated, and secured, and that outdated foods were discarded. Findings include: The facility policy regarding food receiving and storage, dated February 22, 2024, revealed that food items and snacks kept on the nurses' units must be maintained as indicated: All food items to be kept below 41 degrees Fahrenheit must be placed in the refrigerator located at the nurse's station and labeled with a use by date, beverages must be dated when opened and discarded after 24 hours, and other opened containers must be dated and sealed or covered during storage. Observations of the nutrition room's refrigerator on the nursing unit on September 18, 2024, at 11:08 a.m. revealed a thickened dairy drink dated as opened on July 18, 2024. Instructions on the container stated that the thickened milk may be stored up to seven days when refrigerated after opening. Observations also revealed a large container 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's policies, documents, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to provide timely medical record access to residents and/or their legal representative for one of seven residents reviewed (Resident 2). Findings include: The facility's policy regarding access to personal and medical records, dated February 23, 2024, indicated that each resident has the right to access and/or obtain copies of his or her personal and medical records upon request. A resident may submit an oral or written request for access to personal or medical information pertaining to him/her. The resident or his/her legal representative may grant others the right to access the resident's records if such request is made in writing and identifies the information that is to be released and to whom the information was to be released. A durable healthcare power of attorney (POA) form, dated February 15, 2022, indicated that Resident Family Member 1 was the…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to initiate and conduct a thorough investigation to rule out neglect for one of seven residents reviewed (Resident 5). Findings include: The facility's policy regarding accidents and incidents, dated February 23, 2024, indicated that all accidents and incidents involving residents, employees, visitors, and vendors occuring on the premises shall be investigated and reported to the Nursing Home Administrator. The nurse supervisor, charge nurse, and/or the department director or supervisor shall promptly initiate and document an investigation of the accident or incident. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated February 13, 2024, revealed that the resident was usually understood, could usually understand, had diagnoses that included dementia and malnutrition, and had unhealed pressure ulcers. A care plan for the resident, dated April 15, 2024, indicated a potential…

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

Based on review of facility policy, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of seven residents reviewed (Resident 3). Findings include: A facility policy regarding charting and documentation, dated February 23, 2024, revealed that objective observations, medications administered, treatments or services performed, changes in condition, evens, incidents, or accidents involving the resident, and progress toward changes in the care plan goal and objectives should be documented in the medical record. Documentation in the medical record would be objective, complete and accurate. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 8, 2024, revealed that the resident was cognitively impaired, required staff assistance for care needs, and had diagnoses that included dementia and heart failure. Facility investigation documents for Resident 3 revealed…

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

Based on review of policies, clinical records, and facility grievance forms, as well as staff interviews, it was determined that the facility's policy failed to indicate a reasonable expected time frame for completing the review of the grievances, and that the facility failed to make prompt efforts to resolve a grievance by not having documented evidence of the steps taken to investigate the grievance, a summary of the pertinent findings or conclusion regarding the resident's concerns, or any corrective action taken or to be taken by the facility as a result of the grievance for eight of 11 residents reviewed (Residents 4 through 11). Findings include: The facility's grievance policy, dated February 22, 2024, indicated that the nursing home administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer (e.g. Social Services). Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations. The investigation and report will include, as applicable, the date and time of 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 reviews, observations, and staff interviews, it was determined that the facility failed to complete safety assessments to ensure that the use of air mattresses did not create safety hazards for four of 25 residents reviewed (Residents 22, 25, 31, 33). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated January 10, 2024, revealed that the resident was cognitively intact and that he had skin breakdown. Physician's order for Resident 22, dated October 4, 2023, included an order for the resident to have a specialty air mattress. Resident 22's care plan, dated December 14, 2023, indicated that the resident was to have a specialty air mattress. Observations of Resident 22 on February 26, 2024, at 8:56 a.m. revealed that the resident was in bed and lying on an air mattress. There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 22's bed. A significant change MDS…

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 initiate nutritional interventions to prevent weight loss for one of 25 residents reviewed (Resident 11). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated November 16, 2023, revealed that the resident was cognitively intact, was able to make himself understood, could understand others, and did not require staff assistance with meals. A dietician's note for Resident 11, dated January 22, 2024, revealed that the resident experienced a 7.5 percent unplanned weight loss in three months. A physician's order for Resident 11, dated January 27, 2024, revealed that the resident was to have a house supplement twice a day due to weight loss. There was no documented evidence that Resident 11 received the ordered house supplement twice a day from January 27, 2024, to February 1, 2024. Interview with the Dietitian on February 28, 2024, at 8:38 a.m. confirmed that there was no documented evidence…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a tube feeding was documented in accordance with the facility's policy and the resident's care plan for one of 25 residents reviewed (Resident 13). Findings include: The facility's policy regarding enteral feeding (nutritional formula provided via a tube inserted into the stomach), dated November 30, 2022, indicated that nursing staff will monitor for signs and symptoms of aspiration and/or feeding intolerance. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated February 2, 2024, indicated that the resident was cognitively intact, required assistance from staff for all daily care needs, and had a feeding tube (a tube surgically implanted into the stomach for feeding). Resident 13's current care plan, dated September 26, 2023, revealed that staff should check for tube placement and gastric contents/residual volume per the facility's protocol. Physician's orders for…

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

Based on review of facility contracts and clinical records, and staff interview, it was determined that the facility failed to maintain records relating to dialysis communication and collaboration for one of one residents reviewed for dialysis (Resident 37). Findings include: A Quarterly MDS assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated December 21, 2023, revealed that the resident was cognitively intact, required minimal assistance for daily care needs, and was receiving dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). Review of the dialysis contract, dated August, 2022, revealed that the center shall maintain reports of all services rendered by Center in accordance with its usual medical records procedures. Review of Resident 37's clinical record revealed an admission date of November 28, 2023, with diagnoses that included end-stage renal disease (a disease that causes the kidneys not to function properly), diabetes, and hypercholesterolemia (high…

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

Based on review of facility policy 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 three of 25 residents reviewed (Residents 22, 31, 33). Findings include: The policy for narcotic destruction, dated November 30, 2023, revealed that there must be one nurse to destroy a narcotic and one nurse to witness the destruction. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated January 10, 2024, revealed that the resident was cognitively intact and that he had pain. Physician's orders for Resident 22, dated November 17, 2023, included an order for the resident to receive a 5 micrograms (mcg) per hour Buprenorphine patch (narcotic pain medication) and to change the patch weekly. Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 22 for November and December 2023, as well as January and February 2024,…

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, as well as resident and staff interviews, it was determined that the facility failed to serve food items that were palatable. Findings include: Interview with Resident 10 on February 26, 2024, at 9:47 a.m. revealed that she does not like the taste of the food. Interview with Resident 23 on February 16, 2024, at 11:24 a.m. revealed that the food can be hard and the meals are sometimes cold. Interview with Resident 33 on February 26, 2024, at 9:36 a.m. revealed that the food is not very warm. Observations in the kitchen for the lunch meal service on February 27, 2024, at 12:21 a.m. revealed that a test tray left the kitchen and arrived on the [NAME] Room dining area at 12:22 p.m., where one tray was removed from the food cart and at 12:25 p.m. the cart was then transported to the B hall nursing unit and arrived at 12:27 p.m. The lunch meal on February 27, 2024, consisted of barbecue chicken breast, spinach, carrots, macaroni and cheese, mandarin oranges, milk and coffee. Trays were passed to the residents in their rooms and the last resident was served and…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: The facility's policy regarding food storage, dated November 30, 2023, revealed that any food that has been opened must be labeled, dated and secured in such a way that the food item is air tight. Observations in the kitchen's freezer on February 27, 2024, at 9:30 a.m. revealed approximately 30 chicken patties, one-third of a bag of French fries, three-quarters of a bag of Tater tots, 25 egg omelets, and 20 sausage patties that were opened and not labeled, dated or secured. Observations in the kitchen's walk-in dry storage on February 27, 2024, at 11:31 a.m. revealed that there was one opened box with approximately two pounds of loose lasagna noodles and one opened box of approximately five pounds of spaghetti noodles that were not labeled, dated or secured. The facility's policy regarding hair coverings, dated November 30, 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 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 March 2, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 28, 2024, identified repeated deficiencies related to development of comprehensive care plans, revision of residents' care plans, quality of care, safe environment free of accident hazards, proper nutrition and hydration, accountability of controlled substances, labeling of medications, and food stored, prepared and served in a sanitary…

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 provide the required notice to the resident or the resident's representative following the end of their Medicare coverage for three of three residents reviewed (Residents 10, 39, 146) who remained in the facility for long-term care. Findings include: A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility and dated January 19, 2024, revealed that Medicare coverage for Resident 10 started on December 5, 2023, and that her last covered day was January 21, 2024. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility and dated October 10, 2023, revealed that Medicare coverage for Resident 39 started on August 29, 2023, and that her last covered day was October 5, 2023 The form indicated that the facility initiated discontinuation from…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that resident-centered care plans were developed and implemented for two of 25 residents reviewed (Residents 13, 25). Findings include: The facility's policy regarding care plans, dated November 30, 2023, indicated that the facility would develop a written plan of care that was individualized for each resident's daily care routines and would be reviewed and revised as necessary and when a resident experiences a status change. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated February 2, 2024, revealed that the resident was cognitively intact, required assistance from staff for his daily care needs, required oxygen therapy. and had diagnoses that included Parkinson's, heart failure, and dementia. Physician's orders for Resident 13, dated November 21, 2023, included an order for oxygen 3 liters via nasal cannula. There was no documented evidence that a care plan was developed to address Resident…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to review and revise care plans for one of 25 residents reviewed (Resident 25). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated January 2, 2024, revealed that the resident was cognitively impaired, required assistance for daily care needs, received oxygen therapy, had a Stage 3 pressure ulcer (involves the full thickness of the skin and underlying subcutaneous tissue), and had diagnoses that included a stroke, dementia, high blood pressure, and heart failure. A care plan, dated December 17, 2023, indicated the resident's Foley catheter (a tube inserted into the bladder) was an 18 French, 10 cc catheter (size of the catheter). Physician's orders for Resident 25, dated December 27, 2023, included an order for an indwelling Foley catheter, size 16 French 10 cc. Observation of Resident 25 on February 28, 2024, at 9:28 a.m. with the Licensed Practical Nurse Assessment Coordinator…

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 regarding a resident's enteral feeding (feeding through a tube inserted directly into the stomach) and calorie count for one of 25 residents reviewed (Resident 22) and failed to obtain and document a pain level every shift for one of 25 residents reviewed (Resident 33). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated January 10, 2024, revealed that the resident was cognitively intact and that he had a feeding tube. Resident 22's care plan, dated January 6, 2024, indicated that the resident should receive enteral nutrition as ordered. Physician's orders for Resident 22, dated September 28, 2023, and January 13, 2024, included an order for the resident to received Osmolite 1.5 (a type of liquid feed for a feeding tube) at 55 milliliters (mL) per hour for 20 hours per day. A nursing note for Resident 22, dated January 19, 2024, 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 observations and staff interviews, it was determined that the facility failed to ensure that the medication error rate was less than five percent. Findings include: Observations during medication administration on February 26, 2024, at 3:59 p.m. revealed that three medication administration errors were made during 29 opportunities for error, resulting in an error rate of 10.34 percent. Physician's orders for Resident 20, dated November 3, 2023, included an order for the resident to receive 850 milligrams (mg) of Metformin (a medicine used to treat high blood sugar) twice a day. A review of the pill card (a way of packaging medications that are grouped by the time and day of taking them) for Resident 20's Metformin revealed that the pharmacy had placed several additional labels (stickers) on the pill card related to the medication. One label advised that the resident was to receive Metformin with food. Observations during A hall medication pass on February 26, 2024, at 4:13 p.m. revealed that Licensed Practical Nurse 1 administered…

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 ensure that labeling of medication matched physician's orders for three of 25 residents reviewed (Residents 20, 28, 33). Findings include: Physician's orders for Resident 20, dated November 3, 2023, included an order for the resident to receive 850 milligrams (mg) of Metformin (a medicine used to treat high blood sugar ) twice a day. A review of the pill card (a way of packaging medications that are grouped by the time and day of taking them) for Resident 20's Metformin revealed that the pharmacy had placed several additional labels (stickers) on the pill card related to the medication. One label advised that the resident was to receive Metformin with food. Observations during A hall medication pass on February 26, 2024, at 4:13 p.m. revealed that Licensed Practical Nurse 1 administered Resident 20's Metformin with water but no food as per the pharmacy label on the pill card. Physician's orders for Resident 28, dated October 6, 2023, included an order for the resident to receive 25 mg 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 reviews and staff interviews, it was determined that the facility failed to ensure that the physician was notified about the unavailability of medications for two of five residents reviewed (Residents 1, 3). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated September 4, 2023, revealed that the resident was severely cognitively impaired and had a diagnosis of dementia (long and short-term memory loss). Physician's orders for Resident 1, dated September 14, 2023, included orders for the resident to receive 4 milligrams (mg) of Apixaban (blood thinner) twice a day and an order, dated September 15, 2023, for 600 mg of Mucinex (used to treat congestion/excessive mucous production) one tablet twice a day. Review of the Medication Administration Records (MAR) and nursing notes for Resident 1 for October 2023 revealed no documented evidence that the resident was administered Apixaban October 2 at 8:00 a.m.; October 8 at 8:00 a.m.; October 9 at 8:00 a.m. and 4:00…

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.