Hilltop Heights Health & Rehab Center

Based on review of clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to maintain resident dignity for one of 36 residents reviewed (Resident 92). Findings include:A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 92, dated October 30, 2025, revealed that the resident was always understood, always understood others, was cognitively intact, and required assistance from staff for daily care needs. Interview with Resident 92 on January 5, 2026 at 11:30 a.m. revealed that he was moved from his room on another hall recently and that his personal belongings are being stored in his shared bathroom. Observations of Resident 92's bathroom on January 5, 2026 at 11:30 a.m. revealed that there were 4 boxes and one large black garbage bag filled with the resident's personal belongings stored on the floor around the toilet.Interview with the Social Services Director on January 5, 2026 at 11: 48 a.m. revealed that Resident 92's belongings should not have…

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, resident and staff interviews, it was determined that the facility failed to provide a resident with self determination to have a room move for one of 36 residents reviewed (Residents 85).Findings include:The facility's policy regarding room changes, dated August 18, 2025, indicated that a resident or representative could request a room change. A reason for the request could include roommates being incompatible. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 85, dated December 2, 2025, revealed that the resident was understood, could understand others, was cognitively intact, and receives dialysis (life-sustaining treatment for kidney failure that filters waste and extra fluid from your blood). Interview with Resident 85 on January 7, 2026, at 10:34 p.m., revealed that he wants his room changed. He stated that he asked the Social Services Director again yesterday and she said would look into it. Resident 85 explained that his roommate…

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 a resident's care plan was updated/revised to reflect the resident's specific care needs regarding medications for one of 36 residents (Resident 4) and regarding indwelling urinary catheters for one of 36 residents reviewed (Resident 13).Findings include: The facility's policy regarding care plans, dated August 18, 2025, revealed that care plans are reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change in condition. Care plans are evaluated at least with each comprehensive and quarterly assessment. Changes to the care plan due to minor changes in the resident's status will be implemented as indicated. All staff caring for the resident will be familiar with the resident's plan of care.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated November 10, 2025, indicated that the resident was cognitively impaired, required…

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 maintain accountability for controlled medications (drugs with the potential to be abused) for one of 36 residents reviewed (Resident 6). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated October 20, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnosis that included Crohn's disease (a bowel disease that causes inflammation anywhere in the digestive tract, leading to symptoms like abdominal pain), and was receiving scheduled pain medication. Physician's orders for Resident 6, dated October 16, 2025, included orders for the resident to receive 50 micrograms (mcg) of Fentanyl transdermal patch (a narcotic pain medication administered through the skin) to be applied at bedtime every three days for pain. Physician's orders dated November 18, 2025, included to remove the old Fentanyl patch 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 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 plan of corrections for an annual survey ending December 12, 2024, as well as complaint surveys ending March 27, 2025, May 14, 2025, August 11, 2025, and November 13, 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 September January 8, 2026, identified repeated deficiencies related to resident rights, inaccurate MDS assessments, care plan revisions, quality of care, pharmacy services, menus are followed, food that is palatable, and food storage.The facility's plan of correction for a deficiency…

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 and prepare food under sanitary conditions. Findings include:The facility's policy for kitchen sanitation and cleaning, dated August 18, 2025, revealed that the food and nutrition services staff would maintain the sanitation of the kitchen.Observations in the main kitchen on November 13, 2025, at 09:54 a.m. revealed that eighteen out of eighteen coffee mugs as well as three coffee and two water pitchers had loose food particles and a removable brown film inside; six out of ten white dinner plates examined were noted to have a dried on egg and cheese substance on the face of the plate; three out of twenty clear plastic drinking glasses had food particles and grime on them; five out of five large full size sheet pans were noted to have dried on and loose food particles on them; two frying pans were examined, one had a build up of removable brown food particles inside and the other had a moderate amount (five inches by two inches) of a soft yellowish substance…

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 Resident Council/Food Committee meeting minutes, as well as resident, staff interviews and observations, it was determined that the facility failed to make ongoing efforts to resolve grievances presented by the Resident Council/Food Committee.Findings include: Resident Council/Food Committee meeting minutes, dated June 12, 2025, revealed that residents were asked if meals are served hot. One resident stated that her coffee was not at her desired temperature. One resident stated that their French fries were not hot enough. A concern form was generated. Resident Council/Food Committee meeting minutes, dated July 8, 2025, revealed that residents were asked if meals are served hot. Residents in attendance stated their food was not at their desired temperatures. A concern form was generated. Interview with Resident 2 on August 11, 2025, at 9:15 a.m. revealed that her food is not always at her desired temperature when she receives her meals, even with her eating in the main dining room for her lunch and supper meal.Interview with Resident 1 on August 11, 2025, at 9:29…

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 Pennsylvania Code, Professional and Vocational Standards, State Board of Nursing and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a registered nurse assessment was completed with a change in condition for one of four residents reviewed (Resident 3). Findings include:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 23, 2025, revealed that the resident was understood, could understand others, had diagnoses that included heart failure (a condition where the heart muscle cannot pump…

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 Resident Council/Food Committee meeting minutes, as well as observations and interviews with residents and staff, it was determined that the facility failed to serve food that was palatable and at proper temperatures.Findings include:The facility's policy regarding food and nutritional services, dated October 24, 2024, revealed that food will be served at a palatable temperature.Resident Council/Food Committee meeting minutes, dated June 12, 2025, revealed that residents were asked if meals are served hot. One resident stated that her coffee was not at her desired temperature. One resident stated that their French fries were not hot enough. A concern form was generated. Resident Council/Food Committee meeting minutes, dated July 8, 2025, revealed that residents were asked if meals are served hot. Residents in attendance stated their food was not at their desired temperatures. A concern form was generated. Interview with Resident 2 on August 11, 2025, at 9:15 a.m. revealed that her food is not always at her desired temperature when she receives 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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for peripherally-inserted central catheter catheters (PICC-long, thin tube inserted into a vein to deliver fluids or medication) for one of nine residents reviewed (Residents 3). Findings include: The facility's policy for Infusion Maintenance, dated October 24, 2024, indicated that staff were to measure the external catheter length of PICC catheters on admission, with each dressing change, and as needed. An annual minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 3, dated May 13, 2025, revealed that the resident was cognitively intact, required assistance for personal care needs, received intravenous medication, and had diagnoses that included septicemia (a blood infection). Physician's orders for Resident 3, dated April 18, 2025, included orders for the resident's PICC line dressing and securement device to be changed once a day on Tuesdays and as…

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

Based on review of facility policies, and clinical records, as well as observations, and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to drink in accordance with the speech therapist's recommendations and/or physician's orders for one of nine residents reviewed (Resident 8). Findings include: The facility's policy regarding adaptive equipment, dated October 24, 2024, revealed that adaptive equipment to meet the residents needs shall be determined by the therapist and be issued with a provider order (where required or needed). The primary therapist will disseminate the type of equipment and its function to other disciplines during team conference as necessary to increase carry over with proper use. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated May 9, 2025, revealed that the resident was understood, could understand others, had diagnoses that included hemiplegia (paralysis to one side of the body) following a stroke, and was on 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 reviews and staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for two of nine residents reviewed (Residents 2, 9). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 7, 2025, indicated that the resident was cognitively intact and required supervision with showering/bathing herself. A care plan, dated April 14, 2025, revealed that the resident was to be showered twice a week, refused showers at times, and staff were to honor her wishes. The facility's current shower schedule indicated that Resident 2 was to receive a shower/bath on Tuesdays and Saturdays. The resident's bathing records for April and May 2025 revealed that there was no documented evidence that staff provided a shower/bath to the resident or that she refused a shower/bath on Tuesday, April 22 and Fridays, April 26 and May 24, 2025. Interview with Resident 2 on June 9, 2025, at 12:00 p.m. 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 observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions in accordance with professional standards for food service safety. Findings include: Observations in the facility's kitchen area on May 12, 2025, at 9:30 a.m. revealed a garbage can near the employee sink that was overflowing with garbage and a brown, removable substance streaked across the floor beside that garbage can. A garbage can near the dietary department entrance in the hallway was overflowing with garbage and an individual-sized syrup container was opened and spilled on the floor near a nonfunctioning upright cooler in the same area. A dirty glove was observed on the floor near two garbage cans in the cooking prep area. The dishwashing area of the dietary department had an unpleasant, musty odor and there were approximately eight broken floor tiles observed. Water was pooling under the broken floor tiles and a significant amount of water accumulated on the floor under the dishwasher, spreading to the back wall under a long sink,…

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

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a provider's order for treatments for one of eight residents reviewed (Resident 1). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 1, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had one deep tissue injury (a type of injury caused by pressure where damage occurs beneath the skin's surface) on admission, and had diagnoses…

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 essential equipment was in safe operating condition in the facility's kitchen. Findings include: Observations in the facility's kitchen on May 12, 2025, at 9:30 a.m. revealed an accumulation of water on the floor near the dishwasher because the garbage disposal under the commercial dishwasher was broken. A note on the upright hot box read unplug, won't shut off. A note on the steamer read awaiting parts. One of three steam tables was not functioning. A small upright cooler had water pooling inside of it, and the long sink in the dishwashing area had water leaking from two faucets. Interview with the Dietician on May 12, 2025, at 10:50 a.m. confirmed that the garbage disposal under the commercial dishwasher was not functioning, the hot box would not shut off and had to be unplugged to turn it off, the steamer had not been working since it was installed because it was installed with missing parts, one steam table was not working, the small upright cooler had water accumulating in it,…

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

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's representative was notified about a change in condition for one of eight residents reviewed (Resident 1). This was cited as past non-compliance. Findings include: The facility's policy for a resident's change in condition, dated October 24, 2025, indicated that the physician/provider and family/responsible party will be notified as soon as the nurse has identified the change in condition and the resident is stable. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 1, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had one deep tissue injury (a type of pressure ulcer where damage occurs beneath the skin's surface) on admission, and had diagnoses that included a pelvic fracture. A nursing note for Resident 1, dated April 9, 2024, at 7:47 a.m., revealed that new orders 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 clinical records and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for one of eight residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 6, 2024, revealed that the resident was cognitively intact and was dependent on staff for care needs. Review of Resident 2's smoking care plan, dated February 2, 2025, indicated that the resident was non-compliant with the facility's non-smoking policy and was able to go outside with one staff member; however, a smoking safety assessment for Resident 2, dated July 11, 2024, revealed that the resident was safe to smoke independently and did not require staff assistance. Interview with Resident 2 on May 12, 2025, at 11:50 a.m. revealed that he has always gone outside to smoke by himself and has never required a staff member. Interview with the Director of Nursing and Nursing…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with the services necessary to maintain good oral hygiene at bedtime for three of six residents reviewed (Residents 2, 5, 6). Findings include: The facility's policy regarding evening care, dated October 24, 2024, revealed that nursing staff would offer evening care to residents to promote personal hygiene, comfort, relaxation, and safety. Staff were to assemble oral care supplies and assist residents with oral care. A list of residents with dentures provided by the facility included Resident's 2, 5, and 6. A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 2, dated December 23, 2024, revealed that the resident was understood, could understand others, and required staff assistance for set-up with oral care. The resident's care plan, dated January 9, 2025, revealed that the resident was to receive Activities of Daily Living (ADL's) on…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or the resident's responsible party was given the opportunity to participate timely in the development and implementation of a person-centered care plan for one of six residents reviewed (Resident 2). Findings include: A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 2, dated December 23, 2024, revealed that the resident was understood, could understand others, and required staff assistance for her Activities of Daily Living (ADL's). Information provided by the facility revealed that the facility conducted a care plan conference with Resident 2 on October 25, 2024. Interview with the Social Worker and the Registered Nurse Assessment Coordinator (RNAC - registered nurse in charge of the MDS assessments) on March 24, 2025, at 7:15 p.m. revealed that care plan conferences are held quarterly with the residents and resident's responsible party. They…

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 a resident's care plan was updated/revised to reflect the resident's specific care needs for two of six residents reviewed (Residents 1, 2). Findings include: The facility's policy regarding care plans, dated October 24, 2024, indicated that the care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change in condition. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 1, dated March 5, 2025, revealed that the resident was cognitively intact, was at risk for pressure sore development, and had a pressure-relieving device on his bed. The resident's current care plan indicated that the resident was to have an alternating pressure-relief mattress (air mattress that redistributes weight and improves circulation). Observations of Resident 1 on March 24, 2025, at 7:48 p.m. revealed that Resident 1 did 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 the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive annual Minimum Data Set assessments were completed in the required time frame for 35 of 79 residents reviewed (Residents 4, 6, 8, 11, 14, 16, 17, 22, 23, 24, 27, 29, 32, 34, 35, 36, 42, 43, 44, 47, 58, 60, 61, 65, 66, 68, 70, 71, 74, 75, 83, 84, 85, 86, 93). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that an annual MDS assessment was to be completed no later than the assessment reference date (ARD - the last day of the assessment's look-back period) plus 14 calendar days. An annual MDS assessment for Resident 4, with an ARD of October 18, 2024, was due to be completed by October 31, 2024, but was not signed as completed until November 11, 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 review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that Quarterly Minimum Data Set assessments were completed within the required timeframe for 37 of 79 residents reviewed (Residents 1, 2, 3, 5, 9, 12, 13, 15, 18, 20, 21, 27, 28, 31, 33, 36, 37, 38, 39, 40, 45, 48, 51, 52, 54, 55, 56, 57, 59, 67, 68, 72, 73, 76, 78, 82, 85). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of residents' abilities and care needs), dated October 2024, indicated that the completion date for a quarterly assessment is the Assessment Reference Date (ARD - the last day of an assessment's look-back period) plus 14 days. A quarterly assessment is due every 92 days (ARD of most recent assessment + 92 days). A quarterly MDS assessment for Resident 1, with an ARD of November 2, 2024, was due to be completed on November 15,…

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, resident interviews, and staff interviews, it was determined that the facility failed to ensure that dependent residents were provided with the necessary services to maintain personal hygiene, by failing to provide showers as scheduled for one of nine residents reviewed (Resident 5). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated August 7, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, required extensive assistance from staff for personal hygiene, was dependent on staff for bathing, and had diagnoses that included Parkinson's disease. The resident's current shower schedule indicated that he was to receive a shower weekly on Mondays. However, the resident's bathing records for August, September, October, November, and December 2024 revealed that the resident received only three showers since August 1, 2024. Interview with Resident 62 on December 9, 2024, at 11:20 a.m. revealed that he…

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 a resident's weight was obtained and documented as per facility policy for a resident with tube feedings for one of 79 residents reviewed (Resident 1) and failed to ensure that residents maintained acceptable parameters of nutritional status, by failing to ensure timely intervention for weight loss for one of 79 residents reviewed (Resident 62). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 2, 2024, indicated that the resident was rarely/never understood, was dependent on staff for all care, was receiving tube feedings (delivers liquid nutrition through a flexible tube that goes directly into your stomach), and had diagnoses that included traumatic brain injury (disruption of normal function of the brain caused by an outside force). A facility policy for residents' weights revealed that weights are to be obtained routinely in order to monitor nutritional health over time.…

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 written menus, as well as observations and staff interviews, it was determined that the facility failed to follow their planned menu. Findings include: The facility's policies regarding menu planning, as well as sanitization, dated October 24, 2024, indicated that regular and therapeutic menus will be written to provide a variety of foods served on different days of the week, adjusted for seasonal changes, and in adequate amounts at each meal to satisfy recommended daily allowances. The facility's written and posted weekly menu for the lunch meal on December 8, 2024, revealed that the residents were to receive baked fish. The recipe of baked cod, undated, indicated that the cod filets were to be baked with margarine, salt, and white pepper. A test tray completed on November 11, 2024, at 12:12 p.m. revealed that the pureed baked fish was snow white in color when compared to the regular diet portion of baked fish, and there were no seasonings added to the pureed fish. The regular diet portion of baked fished had visible seasonings and margarine added.…

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 a group of residents on December 10, 2024, at 11:15 a.m. revealed that the food delivered to the resident rooms was served cold. Observations in the kitchen for the lunch meal service on December 11, 2024, at 11:58 a.m. revealed that a test tray left the kitchen and arrived on the North hall at 12:00 p.m. The lunch meal on December 11, 2024, consisted of baked fish, broccoli rice casserole, jello, milk, and coffee. The pureed meal had pureed broccoli noodles instead of the casserole. Trays were passed to the residents in their rooms and the last resident was served and eating at 12:12 p.m. The test tray on December 11, 2024, at 12:12 p.m. revealed that the temperature of the baked fish was 114.2 degrees Fahrenheit (F), the pureed baked fish was 104.2 degrees F, the pureed broccoli was 102 degrees F, the pureed noodles was 105.3 degrees F, the broccoli rice casserole was 128.5 degrees F, the jello was…

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored and prepared under sanitary conditions. Findings include: The facility's policies regarding storage of refrigerated foods, as well as sanitization, dated October 24, 2024, indicated that food would be stored in order to maximize food safety and quality, all refrigerated foods prepared and held for more than 24 hours would be marked to indicate the date the food would be consumed or discarded by, and that temperatures for refrigeration were to be between 35 to 39 degrees Fahrenheit with thermometers checked at least twice a day. Observations in the main kitchen on December 9, 2024, at 8:47 a.m. revealed that the walk-in refrigerator had three bags of brussel sprouts with one bag that had a use-by date of November 19, 2024, and the other two had a use-by date of November 25, 2024. The brussel sprouts appeared discolored and had increased moisture in the bags. There was an undated silver tray of cooked chicken tenders, and a bag 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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to maintain the dignity of one of 79 residents reviewed (Resident 97). Findings include: Resident 97 was admitted to the facility on [DATE], and the admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) was not completed as of December 9, 2024. An admission nursing note for Resident 97, dated November 26, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had a diagnosis of chronic ureteropelvic junction obstruction (a blockage causing loss of kidney function), and had a nephrostomy tube (a small tube inserted into the kidney through the skin in the lower back to drain urine into a drainage bag). Observations of Resident 97 on December 9, 2024, at 11:05 a.m. revealed that the resident was being assisted with ambulation to the therapy department by Therapy Assistant 1. While assisting…

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 of a fall to rule out neglect and/or abuse for one of 79 residents reviewed (Resident 39). Findings include: The facility's policy for protection from abuse, neglect, or exploitation, dated October 24, 2024, indicated that the facility will report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property, following federal and state regulations. There was to be immediate notification, but no later than two hours, to the facility's administrator, the Department of Health - Division of Nursing Care Facilities, Area Agency on Aging, and Protective Services if the events that caused the allegation involved abuse or resulted in serious bodily injury, and notification within 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury. A facility policy for fall management, dated…

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 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 five of 79 residents reviewed (Residents 7, 33, 39, 49, 88). 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 2023, indicated that Section J0100B was to be checked yes if the resident was administered any as needed pain medications during the seven-day assessment period. An annual MDS assessment for Resident 7, dated November 7, 2024, indicated that the resident did not receive as needed pain medication during the seven-day assessment period. Physician's orders for Resident 7, dated September 17, 2024, included an order for the resident to receive 0.5 milliliters (ml) of morphine concentrate every two hours as needed for pain or respiratory…

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

Based on clinical record reviews, as well as resident and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized preferences regarding Post Traumatic Stress Disorder (PTSD), Parkinson's Disease, or dementia for two of 79 residents reviewed (Residents 62, 68). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated August 7, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis that included Parkinson's disease. Discharge instructions for Resident 62, dated September 2, 2024, revealed that the resident was diagnosed with vascular dementia. Physician's orders for Resident 62, dated September 2, 2024, included an order for the resident to receive 25-250 milligrams (mg) carbidopa-levodopa three times per day (used to treat Parkinson's disease) and 5 mg donepezil nightly (for dementia). There was no evidence that Resident 62 had a care…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for three of 79 residents reviewed (Residents 7, 39, 72). Findings include: A facility policy for comprehensive care planning, dated October 24, 2024, indicated that the care planning coordinator will add minor changes in the resident's status to the existing care plan on a daily basis. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated November 7, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, was receiving hospice care, and had diagnoses that included stroke. A care plan for Resident 7, dated December 25, 2023, indicated that the resident was receiving antidepressant medication. A care plan, dated November 1, 2023, indicated that the resident was receiving antianxiety medication. Review of the Medication…

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 residents received care and treatment in accordance with professional standards of practice by failing to ensure that physician's orders were followed for one of 79 residents reviewed (Resident 7). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated November 7, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, was receiving hospice care, and had diagnoses that included stroke. Physician's orders for Resident 7, dated August 28, 2024, included an order for the resident to have her right dorsal (top) foot and right mid planter (bottom) foot cleansed with wound cleaner, swabbed with betadine (solution used to prevent infections), and secured with nonwoven gauze daily. Physician's orders, dated November 14, 2024, included orders for the resident to receive 15 milligrams (mg) of immediate release morphine…

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

Based on a review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to safely transfer one of 79 residents reviewed (Resident 39) who required assistance from staff for transfers. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated September 17, 2024, revealed that the resident was understood and able to understood others, was dependent on staff for chair/bed-to-chair transfers, and had diagnoses that included flaccid hemiplegia affecting his left dominant side (condition where a person has a complete lack of voluntary movement in one side of their body). Physician's orders for Resident 39, dated October 8, 2024, included that the resident be transferred with the assist of two staff. A nurse's note for Resident 39, dated December 5, at 4:41 a.m., revealed that on December 4, 2024, at around 7:45 p.m. the resident was observed to be on the floor in his room between the bed and the window wall. He was assessed, had no injuries, and…

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

Based on a review of clinical record reviews and staff interviews, it was determined that the facility failed to ensure that there was timely physician notification and intervention for a significant weight loss for residents with a tube feed (surgically implanted tube for artificial feeding) for two of 79 residents reviewed (Residents 66, 78). Findings include: The facility's policy regarding tube feeds, dated October 24, 2024, revealed that staff would maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. A quarterly Minimum Data Set (MDS a mandated assessment of a resident's abilities and care needs) assessment for Resident 66, dated November 5, 2024, revealed that the resident is severely cognitively impaired, requires extensive assistance from staff for all daily care needs, had diagnoses that included stroke, and had a feeding tube (tube surgically inserted into the stomach…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to obtain a physician's order for oxygen therapy for one of 79 residents reviewed (Resident 5). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated October 28, 2024, revealed that the resident had moderate cognitive impairment, required assistance from staff for care needs, and had diagnoses that included chronic respiratory failure. A care plan for Resident 5, dated July 26, 2024, indicated that the resident required oxygen therapy for chronic respiratory failure, and that staff were to explain the importance of keeping the oxygen at the prescribed setting, stressing more oxygen may not be better. Observations of Resident 5 on December 9, 2024, at 10:50 a.m. and December 12, 2024, at 12:59 p.m. revealed that the resident was sitting in her wheelchair in the hallway with oxygen being administered at four liters per minute. Observations on December…

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, a pharmacy delivery schedule, a list of emergency medications kept at the facility, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to provide pain management for one of 22 residents reviewed (Resident 62). Findings include: The facility's policy regarding pain management, dated January 14, 2019, indicated that staff would implement the pain management program, including evaluation/re-evaluation for residents experiencing either acute or chronic pain. The policy also indicated that pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does. Staff were to obtain information from the evaluation process to determine what level of pain will interfere with the resident's quality of life and prohibit him/her from carrying out normal life activities. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated August 7, 2024, revealed that the resident was cognitively intact, required…

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 personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually, based on hire dates, for three of three nurse aides reviewed (Nurse Aide 3, Nurse Aide 4, Nurse Aide 5). Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation for Nurse Aide 3 was due July 1, 2024. As of December 12, 2024, there was no documented evidence that the annual performance evaluation was completed as required for Nurse Aide 3. A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation for Nurse Aide 4 was due July 1, 2024. As of December 12, 2024, there was no documented evidence that the annual performance evaluation was completed as required for Nurse Aide 4. A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation for Nurse Aide 5 was due July…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 76 residents reviewed (Resident 89). Findings include: The facility's policy regarding controlled substance disposal, dated October 24, 2024, indicated that the destroying/disposal of controlled drugs should be conducted according to federal and state regulations. Destruction of controlled medications should be documented on the controlled medication count sheet and signed by the registered nurse and a witnessing licensed professional. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 89, dated October 27, 2024, revealed that the resident was cognitively impaired, received an antianxiety medication, and had diagnoses that included Metabolic Encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood the affects the brain). Physician's orders for Resident 89, dated…

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 respond timely to a pharmacy recommendation for one of 79 residents reviewed (Resident 72). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 72, dated November 3, 2024, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, received routine and as needed pain medication, and had diagnosis that included diabetes. Review of a pharmacy Medication Regimen Review (MRR) recommendation for Resident 5, dated July 7, 2024, recommended that the physician consider ordering Senna (stimulant laxative to treat constipation) once daily at bedtime, while continuing to monitor for signs and symptoms of constipation. There was no documented evidence that the pharmacy recommendation was reviewed by the physician. Interview with the Director of Nursing on December 12, 2024, at 1:38 p.m. confirmed that there was no documented…

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) surveys ending January 18, 2024; February 23, 2024; June 19, 2024; September 19, 2024; and October 21, 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 December 12, 2024, identified repeated deficiencies related to failure provide notice of bed hold policy, failure to complete comprehensive assessments timely, failure to develop resident care plans, failure to provide activities of daily living care to dependent residents, failure to provide…

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

Based on review of manufacturer's direction for use, as well as observations and staff interviews, it was determined that the facility failed to ensure essential equipment was in safe operating condition in the facility's main kitchen. Findings include: Observations in the main kitchen on December 9, 2024, at 8:47 a.m. revealed that the steamer had a note that it was broken and not to use it. Interview with the Corporate Dietary Manager on December 10, at 1:38 p.m. revealed that she has been with the company for about one and a half years and the steamer has not worked since she has been there. The steamer was not repairable and the facility was in the process of reordering a new one. Interview with the Nursing Home Administrator on December 11, 2024, at 3:15 p.m. confirmed that the steamer was not functioning and that the facility was currently receiving price quotes about purchasing a new steamer. 28 Pa. Code 207.2 (a) Administrator's Responsibility.

Based on review of written menus and the residents' meal ticket, as well as observations and resident and staff interviews, it was determined that the facility failed to follow their planned menu for one of seven residents reviewed (Resident 2). Findings include: The facility's written menu for the breakfast meal on Monday, October 21, 2024, revealed that as part of the resident's meal he was to receive an egg, bacon and cheese croissant sandwich and two bowls of hot cereal. Observations of Resident 2's breakfast tray on October 21, 2024, at 8:25 a.m. revealed that his tray ticket indicated that he was to receive an egg, bacon and cheese croissant sandwich and two bowls of hot cereal However, his tray included scrambled eggs with cheese melted on top, two bowls of cold cereal, and two pieces of toast. Interview with Resident 2 on October 21, 2024, at 8:25 a.m. revealed that he often does not get what his tray ticket says, and that he has told the kitchen, and he does not understand what is going on in the kitchen. Interview with the Corporate Dietary Manager on October 21, 2024, 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 observations and staff interviews, it was determined that the facility failed to provide a clean, homelike environment for one of nine residents reviewed (Resident 3). Findings include: The facility's policy titled Cleaning and Disinfection of Resident Care Equipment, dated October 31, 2023, revealed that the policy objective was to provide a safe, clean environment and equipment for residents. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated September 7, 2024, revealed that the resident was cognitively intact, required assistance with most daily care needs, and had diagnoses that included multiple sclerosis (a chronic disease that effects the nervous system). Observation of Resident 3 lying on the bed in her room on September 19, 2024, at 4:10 p.m. with her wheelchair beside the bed revealed that there was a heavy accumulation of removable dust/debris on the wheels and the metal supports under the chair. There was also a white, stuck-on substance under the wheelchair seat cushion and…

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

Based on review of facility policy, clinical record reviews, and staff interviews, it was determined that the facility failed to follow physician's orders for medication and failed to conduct neurological checks per policy after a fall for one of nine residents (Resident 4) reviewed. Findings include: A facility policy regarding neurological checks, revised July 9, 2024, indicated that a neurological check (a series of tests and questions that assess a patient's nervous system) would be provided by a licensed professional to all residents who have sustained a witnessed, unwitnessed, alleged, reported, or suspected head trauma following an unusual occurrence or change in resident neurological condition. Unless otherwise ordered by the physician, the frequency of neurological assessments will be once every shift for 72 hours post occurrence or change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated August 16, 2024, revealed that the resident was understood, could understand, was cognitively impaired,…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the call bell system was in full working order for the residents on the North hall. Findings include: The facility's policy titled Call Lights: Resident Communication System Accessibility, dated October 31, 2023, revealed that the facility is to be adequately equipped with a call bell system that functions properly through the facility. Interview with Nurse Aide 3 on September 19, 2024, at 11:02 a.m. revealed that when a resident activates the call bell on North hall, the light above the resident's room comes on but the sound is not activated. She also revealed that the central call light for the North hall always stays on; this is a light on the ceiling by the nurse's station that makes the nurse aware that a call bell is going off. This light never turns off despite all call bells being answered. She further indicated that with the central light and bell tones not functioning properly, it has made it difficult to know when a bell…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for the care of a Peripherally Inserted Venous Catheter (PICC a type of long-term intravenous catheters) for one of five residents reviewed (Resident 4). Findings include: A facility policy for intravenous catheters, dated October 31, 2023, revealed that dressings for PICC lines will be changed weekly or as needed per physician's orders. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated June 28, 2024, indicated that the resident was cognitively intact, required assistance from staff for care, had a PICC line, and received intravenous (IV- administered directly into a vein) medication. Physician's orders for Resident 4, dated July 13, 2024, included an order for the resident to receive a PICC line dressing and cap change weekly on Mondays. There was no documented evidence in Resident 4's clinical record to indicate that the PICC line…

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 reviews and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of five residents reviewed (Resident 1). This deficiency was cited as past non-compliance. Findings include: Physician's orders for Resident 1, dated June 25, 2024, included orders for the resident to receive one 200 milligrams (mg) tablet of lacosamide (medication for seizures) twice a day. A nurse's note for Resident 1, dated July 19, 2024, at 11:30 p.m., revealed that the nurse administered two 200 mg tablets of lacosamide instead of one, and the physician ordered the resident be sent to the emergency room for observation. A nurse's note for Resident 1, dated July 23, 2024, at 4:31 p.m., revealed that the resident returned to the facility at 10:30 a.m. after being admitted to the hospital on [DATE], due to vomiting after receiving two 200 mg tablets of lacosamide. Interview with the Director of Nursing on August 28, 2024, at 2:30 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.

Based on a review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan (includes the minimum healthcare information necessary to properly care for a resident) was developed and implemented to include information regarding the resident's immediate care needs for one of four residents reviewed (Resident 3). Findings include: A facility policy for baseline care plans, dated October 31, 2023, revealed that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident including the minimum healthcare information necessary to care for a resident. The baseline care plan will be developed with 48 hours of admission. Review of clinical records for Resident 3 revealed that the resident was admitted to facility on June 14, 2024, with and order to receive an intravenous (administration of fluids and/or medications directly into a person's vein) antibiotic for cellulitis (a bacterial…

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 accommodate the resident's preference for a shower for one of eight residents reviewed (Resident 4). Findings include: The facility's policy regarding bath/showering, dated October 31, 2023, indicated that residents will be bathed or showered according to their preferences to maintain healthy hygiene and skin condition. Each resident will be asked about his/her bathing preferences upon admission. Each resident will be scheduled to receive bathing a minimum of two times per week unless they prefer less frequent baths or state regulations requires more frequent bathing. The facility will develop and maintain a bathing/shower schedule for each unit. When the bath or shower is complete, the nursing assistant will document the activity on the shower sheet or in the electronic medical record. If the bath/shower cannot be given or if the resident refuses, the nursing assistant will promptly report this to the charge nurse. The charge nurse will speak with the…

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

Based on review of facility policies, clinical records, and shower schedules, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers and/or showers as scheduled for three of eight residents reviewed (Residents 1, 2, 6). Findings include: The facility's policy regarding bath/showering, dated October 31, 2023, indicated that residents will be bathed or showered according to their preferences to maintain healthy hygiene and skin condition. Each resident will be scheduled to receive bathing a minimum of two times per week unless they prefer less frequent baths or state regulations requires more frequent bathing. The facility will develop and maintain a bathing/shower schedule for each unit. When the bath or shower is complete, the nursing assistant will document the activity on the shower sheet or in the electronic medical record. If the bath/shower cannot be given or if the resident refuses, the nursing assistant will promptly report this to the charge nurse. The charge nurse will speak with the resident who refuses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive annual Minimum Data Set assessments were completed within the required time frame for seven of 34 residents reviewed (Residents 18, 21, 51, 54, 56, 59, 61). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600), and that an annual MDS assessment was to be completed no later than the assessment reference date (ARD - the last day of the assessment's look-back period) plus 14 calendar days. A comprehensive admission MDS assessment for Resident 18, with and ARD of November 14, 2023, was completed…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or responsible party was notified about the facility's bed-hold policy upon transfer to the hospital for one of 34 residents reviewed (Resident 30). Findings include: The facility's policy for bed holds, dated October 31, 2023, indicated that the facility will track Medicaid bed-hold days and notify appropriate parties via a Medicaid bed-hold letter. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 30 dated December 13, 2023, revealed that the resident was cognitively impaired, required extensive assistance with daily care needs, and had diagnoses that included diabetes mellitus and cerebral palsy (a disorder that affects the ability to move and maintain posture and balance). A nursing note for Resident 30, dated July 29, 2023, at 5:58 a.m. revealed that the resident was admitted to the hospital for a change in condition. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a baseline care plan included resident-specific information necessary to properly care for one of 34 residents reviewed (Resident 74). Findings include: The facility's policy for baseline care plans (includes the minimum healthcare information necessary to properly care for a resident), dated October 31, 2023, indicated that the facility would develop and implement a baseline care plan within 48 hours of admission. The baseline care plan will include the instructions needed to provide effective and person-centered care of the resident and will be used until the comprehensive care plan is developed. A nurse's note for Resident 74, dated January 4, 2024, at 9:39 p.m., indicated that the resident was admitted to the facility with a diagnosis of End Stage Renal Disease (ESRD) (kidneys fail to work), congestive heart failure (heart does not pump blood well enough to meet…

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 develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of 34 residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 31, 2023, revealed that the resident was severely cognitively impaired, was rarely/never understood, was dependent on staff for all daily care needs, and had diagnoses that included quadriplegia (paralysis that affects all four limbs and torso), seizure disorder, other specified disorders of the brain, and that she had a percutaneous endoscopic gastrostomy (PEG - a tube inserted in the stomach through the abdominal wall to provide nutrition). Physician's orders for Resident 2, dated November 28, 2023, included an order to administer 250 milliliters (ml) of IsoSource HN 1.2 kilocalorie (kcal) (a liquid nutrient source) by PEG tube every four hours.…

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

Based on review of clinical records, as well as staff interviews and observation, it was determined that the facility failed to ensure that care was provided to residents in accordance with professional standards of practice, by failing to clarify a physician's order for fluid restriction for one of 34 residents reviewed (Resident 58). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58, dated October 14, 2023, indicated that the resident was cognitively intact, required moderate assistance from staff for daily care activities, had diagnoses that included end-stage renal (kidney) failure, and required hemodialysis (an invasive procedure that cleans the blood when the kidneys no longer function properly). Physician's orders for Resident 58, dated November 14, 2023, included an order for the resident to have a fluid restriction of 1500 milliliters (ml) per day. Physician's orders, dated December 29, 2023, included an order for the resident to have a fluid restriction of 1000 milliliters (ml)…

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 for enteral feedings (feeding through a tube inserted directly into the stomach) were followed for one of 34 residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 31, 2023, indicated that the resident was severly cognitively impaired, required maximum assistance from staff for care, and had an enteral feeding tube. Physician's orders for Resident 2, dated August 8, 2023, included an order for the resident's feeding tube to be flushed with 100 milliliters (mL) water every four hours and an additional 60 cubic centimeters (cc) free water before and 30 cc between medications and to record amounts every shift. Review of Resident 2's December 2023 and January 2024 Medication Administration Record (MAR) revealed that there was no documentation of the amount of water administered in flushes each shift per 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for one of 34 residents reviewed (Resident 62). Findings include: The facility's policy regarding preparation and medication administration, dated October 31, 2023, indicated that staff should document the administration of controlled substances in accordance with applicable law. The facility's policy regarding routine reconciliation of controlled substances, dated October 31, 2023, indicated that the facility should conduct routine reconciliation of controlled substances by comparing the total number of doses originally dispensed by the pharmacy to the number of doses administered according to the resident's medication administration record (MAR). An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated November 7, 2023, revealed that the resident was cognitively intact; required substantial…

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 manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that keys to the medication room were secured, failed to label multidose vials of tuberculin (solution used to detect tuberculosis infection), and failed to label multi-dose inhalers with the date they were opened in two of two medication carts reviewed (East cart and North cart). Findings include: The facility's policy regarding medication administration, dated October 31, 2023, indicated that the facility should ensure that medication carts are always locked when out of sight or unattended. Observations on January 17, 2024, at 7:55 a.m. revealed that Licensed Practical Nurse 1 entered a resident's room while leaving the keys to the medication cart unsecured and lying on top of the medication cart in the hallway. The keys and the cart were out of her line of site while she administered medications to the resident. Interview with Licensed Practical Nurse 1 on January 17, 2024, at 7:55 a.m. revealed that she was…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending February 2, 2023, and August 8, 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 January 18, 2024, identified repeated deficiencies related to quality of care and pharmacy services, procedures and records. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending February 2, 2023, and August 8, 2023, revealed that quality of care would be monitored by…

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 policies, as well as observations and staff interviews, it was determined that the facility failed to store food in a sanitary manner. Findings include: The facility's policy regarding food labeling, dated October 31, 2023, indicated that all foods were to be properly dated and labeled to ensure food safety. The facility's policy regarding food storage, dated October 31, 2023, revealed that all food storage areas were to be maintained in a clean, safe, and sanitary manner, and food was not to be exposed or subjected to contamination by condensation or leakage. Observations in the walk-in freezer on December 27, 2023, at 8:15 a.m. revealed that there was a large accumulation of ice on the fan in the freezer and approximately one inch accumulation of ice on a box of undated beef liver that was stored below the fan. Interview with the Dietary Director on December 27, 2023, at 11:39 a.m. confirmed that there should not be ice build-up in the freezer, and the beef [NAME] should have been dated and…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that safe transfer equipment and techniques were used for one of six residents reviewed (Resident 6) who required the use of a mechanical lift for transfers. Findings include: The facility's policy regarding falls, dated September 5, 2023, indicated that residents would be assessed for fall risks on admission, quarterly, after any fall, and as needed. If risks were identified, preventative measures would be put in place and care planned. All falls would be reviewed and investigated and individualized interventions would be implemented based on the assessment and care planned accordingly. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated August 1, 2023, revealed that the resident was cognitively intact, was dependent for transfers, had limited range of motion on one side, and had diagnoses that included hemiplegia (muscle weakness or partial paralysis on one side 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 review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for one of four residents reviewed (Resident 2). Findings include: An Annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 10, 2023, revealed that the resident was cognitively intact, required extensive assist with daily care needs, and had diagnoses that included ulcerative colitis (inflammatory bowel disease) and atrial fibrillation (rapid irregular heart beat). Physician's orders for Resident 2, dated June 23, 2023, included an order for the resident to receive 2250 milligrams (mg) of balsalazide (an ulcerative colitis medication) three times daily with special instructions that three capsules were to be administered. Physician's orders for Resident 2, dated June 23, 2022, included an order for the resident to receive 5 mg of Eliquis (blood thinning medication) twice a day. A review of the Medication Administration Records (MAR's)…

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

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that its medication error rate was less than 5 percent. Findings include: Observations during medication administration on August 8, 2023, revealed that two medication administration errors were made during 31 opportunities for error, resulting in a medication error rate of 6.45 percent. Physician's orders for Resident 2, dated June 23, 2023, included an order for the resident to receive 2250 milligrams (mg) of balsalazide (an ulcerative colitis medication) three times daily with special instructions that three capsules were to be administered. Physician's orders for Resident 2, dated June 23, 2023, included an order for the resident to receive 1000 (mg) of metformin (diabetic medication) twice daily with special instructions that two tablets were to be administered. Observations during medication administration on August 8, 2023, at 9:13 a.m. revealed that Registered Nurse 1 administered 750 mg of balsalazide (one capsule) and 500 mg of metformin (one capsule)…

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.