Richland Nursing And Rehab

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that oxygen was provided as ordered by the physician for one of four residents reviewed (Resident 3). Findings include: The facility's policy regarding oxygen use, dated May 8, 2024, indicated that the facility was to verify the physician's order and provide safe oxygen administration. An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 20, 2024, revealed that the resident was severely cognitively impaired and received oxygen. A care plan, dated November 27, 2024, revealed that Resident 3 was at risk for respiratory impairment related to congestive heart failure (CHF) and had a history of pneumonia. Physician's orders, dated November 30, 2024, included an order for the resident to receive oxygen at zero to four liters per minute (lpm) every shift to maintain an oxygen saturation (measurement of the percentage of oxygen-rich hemoglobin in…

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

Based on review of planned, written menus, and recipes, as well as observations and staff interviews, it was determined that the facility failed to follow their pre-approved planned menu and recipes. Findings included: Review of the posted menus for the lunch meal on Thursday, December 19, 2024, revealed that residents were to receive chicken vegetable stew, spaghetti noodles, dinner roll, pineapple tidbits with cream, two-percent milk, coffee/tea, and margarine. A facility recipe card for chicken and vegetable stew, dated September 6, 2015, indicated that the chicken and vegetable stew contained the following 19 ingredients: fully cooked 1/2-inch diced chicken that was 80 percent dark and 20 percent white, chopped ham, chicken broth, baby lima beans, corn, crushed tomatoes, diced celery, chopped onions, minced garlic, ketchup, red wine vinegar, sugar, Worcestershire sauce, paprika; marjoram, pepper, salt, hot sauce, and margarine. Observations on December 19, 2024, at 11:46 a.m. during the lunch tray delivery revealed that the residents received a bowl containing the spaghetti…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative in writing of the transfer and reason for hospitalization for six of 37 residents reviewed (Residents 9, 28, 36, 37, 43, 62). Findings include: A nursing note for Resident 9, dated August 11, 2024, at 12:17 p.m., revealed that the resident had a large emesis, had acute abdominal pain, and a history of bowel obstruction (partial or complete blockage of the small or large intestine). The physician was notified, and the resident was sent to the hospital for an evaluation. He was admitted with a urinary tract infection and small bowel obstruction. There was no documented evidence that a written notice of Resident 9's transfer to the hospital and reason for hospitalization was provided to the resident's representative. A nursing note for Resident 28, dated October 22, 2024, at 8:06 p.m., revealed that the resident was transferred to the hospital and admitted with a heart attack. There was no documented evidence that a written notice of…

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

Based on review of the Pennsylvania's Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a questionable physician's order for three of 37 residents reviewed (Residents 19, 63, 76). 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. Physician's orders for Resident 19, dated October 11, 2024, included an order for staff to flush the resident's feeding tube (a medical device that provides nutrition, fluids, and medication to people who are unable to eat or drink safely by mouth) with 50 milliliters (ml) of water before and after administering medications and flush with 5 ml of water between each 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to complete neurological checks per protocol following a fall for one of 37 residents reviewed (Resident 37) and failed to ensure that medications were provided as ordered by the physician for one of 37 residents reviewed (Resident 76). Findings include: The facility's examination and assessment policy, dated November 21, 2024, indicated that the purpose was to examine and assess the resident for any abnormalities in their health status, one way to do this was to use a neurological assessment flow sheet. The neurological assessment form indicated that neurological checks would be completed every 15 minutes for one hour, every hour for four hours, and every four hours for 19 hours. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated October 9, 2024, indicated that the resident was moderately cognitively impaired and had diagnoses that included peripheral vascular disease (a slow,…

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 facility investigations, 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 two of 37 residents reviewed (Residents 36, 59). This deficiency was cited as past non-compliance. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated November 21, 2024, revealed that the resident was cognitively intact, was understood and understands, required assistance with care needs, had occasional pain, received pain medication routinely and as needed, and received an opioid (a controlled pain medication). Physician's orders for Resident 36, dated April 16, 2024, included and order for the resident to receive 10 milligrams (mg) of Oxycodone every six hours as needed for pain related to chronic pain syndrome. An investigation by the facility, dated June 7, 2024, revealed that during audits for drug diversion it was noted that 60 tablets of…

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

Based on review of established infection control guidelines, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of 37 residents reviewed (Residents 19, 62, 76). Findings include: CDC guidance on Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicated that multidrug-resistant organism (MDRO) transmission was common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection…

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

Based on review of facility policy and clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide reasonable accommodation of a resident's needs by failing to ensure that the call bell was within reach for one of 37 residents reviewed (Resident 2). Findings include: The facility's policy regarding call bells, dated November 21, 2024, revealed that the call bell should be within reach of the resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 6, 2024, indicated that the resident was understood and could understand, was cognitively impaired, and was dependent on staff for all care needs. The resident's current care plan indicated that the resident had decreased mobility and that staff were to ensure the call bell was within reach. Observations of Resident 2 on December 16, 2024, at 10:15 a.m. revealed that the resident was lying in bed and was asking for her call bell. The call bell was in her nightstand drawer and was not within…

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

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that the resident and/or responsible party was notified about the facility's bed-hold policy upon transfer to the hospital for three of 37 residents reviewed (Residents 9, 37, 43). This deficiency was cited as past noncompliance. Findings include: A nursing note for Resident 9, dated August 11, 2024, at 12:17 p.m., revealed that Resident 9 had a large emesis, had acute abdominal pain, and a history of bowel obstruction (partial or complete blockage of the small or large intestine). The physician was notified, and the resident was sent to the hospital for an evaluation. He was admitted with a urinary tract infection and small bowel obstruction. There was no documented evidence that Resident 9 and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfers to the hospital. A nursing note for Resident 37, dated June 29, 2024, at 3:00 a.m. revealed that Resident 37 was found lying on his floor mat between the wall and bed. No…

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 four of 37 residents reviewed (Residents 35, 36, 48, 60). Findings include: The Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, revealed that Section N0300 was to indicate if the resident received any type of injection during the last seven days and Section H0100A was to indicate if the resident had a nephrostomy tube (a tube inserted through the skin into the kidney that carries urine from the kidney to the bladder). Physician's orders for Resident 35, dated October 7, 2024, included an order for the resident's nephrostomy tube site be cleansed with normal saline solution and a dry dressing applied daily. A nursing note, dated November 10, 2024, revealed that the resident had a…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for four of 37 residents reviewed (Residents 28, 33, 39, 68). Findings include: The facility's policy regarding care plans, dated November 21, 2024, indicated that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). A quarterly MDS assessment for Resident 28, dated September 26, 2024, revealed that the resident was cognitively impaired, was understood and able to understand others, 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 clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to apply dressings to pressure ulcers as ordered by the physician for one of 37 residents reviewed (Resident 19). Findings include: A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated December 3, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included Stage 4 Pressure Ulcer (damage extends through all layers of skin, reaching the underlying muscle, tendon, or bone, often with exposed tissue) to his left heel, and a non-stageable pressure ulcer (unable to determine the depth of the wound) to another site. A care plan for the resident, dated November 6, 2024, revealed that the resident had an actual skin breakdown to his left great toe and staff was to administer the treatment per the physician's orders. Physician's orders for Resident 19, dated December 13, 2024, included an order for staff to cleanse the…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an intravenous line (a medical technique that administers fluids, medications, and nutrients directly into a person's vein) was flushed in accordance with facility policy for one of 37 residents reviewed (Resident 10). Findings include: The facility's policy regarding flushing midline (a thin, flexible tube that is inserted into a vein in the upper arm to deliver intravenous fluids or medicine) and central line (a long, flexible tube that is inserted into a large vein to provide access to the heart) intravenous catheters, dated November 21, 2024, revealed that midline and central line intravenous catheters will be flushed to maintain patency, to prevent mixing of incompatible medications and solutions, and to ensure entire dose of solution or medication is administered into the venous system. Flush catheters at regular intervals to maintain patency and before and after following administration of medication. Use the SASH method (saline, administer…

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, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to label multi-dose containers of inhalers with the date they were opened in one of two medication carts reviewed (B-wing med cart), failed to discard a discontinued insulin pen in one of two medication carts reviewed (B-wing med cart), failed to obtain temperatures for the medication room refrigerator on the night shift, and failed to properly secure medications in the medication cart (C-wing med cart). Findings include: Manufacturer's directions for use of Fluticasone-Salmeterol (an inhaled medication used to help open the airways and make it easier to breathe), dated April 2008, indicated to discard Fluticasone-Salmeterol diskus one month after opening the foil tray or when the counter reads 0, whichever comes first. Write the Pouch opened and Use by dates on the label on top of the diskus. The Use by date is one month from date of opening the pouch. Physician's orders for Resident 2, dated August 11,…

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 correction for the State Survey and Certification (Department of Health) survey ending January 11, 2024, revealed that the facility developed plans of corrections 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 19, 2024, identified repeated deficiencies related to quality of care/following physician's orders, treatment of pressure ulcers, medication storage and labeling, and following infection control practices. The facility's plan of correction for a deficiency regarding quality of care/failure to follow physician's orders, cited during…

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

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident or the resident's representative was notified about a transfer to the hospital and changes in medication orders for one of four residents reviewed (Resident 1). Findings include: The facility's policy regarding residents' rights, dated November 21, 2024, revealed that the facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there is a need to alter treatment significantly or when there is a decision to transfer the resident from the facility. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 1, 2024, revealed that the resident had moderate cognitive impairment, required assistance from staff for daily care needs, and had diagnoses that included epilepsy (chronic brain disorder that causes seizures) and gastrointestinal stromal…

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 resident and staff interviews, it was determined that the facility failed to ensure that a reasonable accommodation of a resident's preferences for toileting was provided for two of six residents reviewed (Residents 1, 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 7, 2024, revealed that the resident was understood and able to understand others, required assistance with care needs, was frequently incontinent of bowel and bladder, and had a diagnosis of Malignant Carcinoid Tumor of Stomach (stomach cancer). A care plan for Resident 1, revised on April 12, 2024, revealed that the resident had a potential for alteration in bowel elimination related to the need for assistance with toilet use, occasional incontinence, occasional diarrhea, bouts of constipation, and GI tumor. An interview with Resident 1 on June 20, 2024, at 5:24 p.m. revealed that she does not get toileted during meals. She stated that the staff are not allowed to toilet…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to follow physician's orders for two of 29 residents reviewed (Residents 61, 66). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 61, dated August 10, 2023, revealed that the resident was alert and oriented and required extensive assistance with care. Physician's orders for Resident 61, dated May 4, 2023, included an order for the resident to have a size 18F, 30 cc indwelling foley catheter (a thin, flexible catheter used to drain urine from the bladder). Observations on January 10, 2024, at 10:08 a.m. revealed that Resident 61 had a size 18F, 10 cc indwelling foley catheter in place. Interview with the Director of Nursing on January 11, 2024, at 11:29 a.m. confirmed that the foley catheter in place for Resident 61 was not what the physician ordered. A significant change MDS assessment for…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for one of 29 residents reviewed (Resident 55). Findings include: An admission Minimum Data Set (MDS) for Resident 55, dated October 7, 2023, revealed that the resident had diagnoses that included COPD (congestive obstructive pulmonary disease- a lung disease), was cognitively intact, required extensive assistance from staff for personal care needs, had a history of pressure ulcers on the sacrum and behind the ears, and a need for palliative care (focuses on providing relief from pain and other symptoms of a serious illness). Review of wound consultation notes for Resident 55, dated November 21 and 28, 2023, and December 5, 2023, and January 11, 2024, revealed that pressure from the oxygen tubing was contributing to the resident having continued off and on skin breakdown behind the ears. Wound consultant recommendations included the continued use of foam protectors on the oxygen tubing behind the residents ears. Physician's orders for…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to conduct an air mattress safety assessment for one of 29 residents reviewed (Resident 33) and failed to ensure that the residents' environment remained as free of accident hazards as possible by transporting a resident without leg rests for one of 29 residents reviewed (Resident 139). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated May 8, 2023, revealed that he was cognitively impaired, required extensive assistance from staff for care, and had an indwelling urinary catheter. A care plan for the resident, dated June 2, 2023, revealed that he was at risk for falls due to balance, and interventions, dated July 13, 2023, included an alternating air mattress. A nursing note for Resident 33, dated July 10, 2023, at 9:30 p.m., indicated that the nurse was called to resident's room by a nurse aide. The resident was lying on his right side…

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

Based on review of policies, clinical records, and 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 29 residents reviewed (Resident 79). Findings include: The facility's policy regarding enteral feeding, dated September 21, 2023, indicated that the enteral nutrition is based on a dietician's nutritional assessment. Physician's orders for enteral nutrition are based off the recommendations from the dietician. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 79, dated November 7, 2023, indicated that the resident was cognitively intact and required assistance from staff for care. Physician's orders for Resident 79, dated November 16, 2023, included an order for the resident to receive a bolus (one meal of formula) of Osmolite (a type of formula) four times a day (9:00 a.m., 1:00 p.m., 6:00 p.m., and 8:00 p.m.) for meal intakes that were less than 50 percent.…

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 provide medication as ordered by the physician, resulting in significant medication errors for one of 29 residents reviewed (Resident 1). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 28, 2023, revealed that the resident was cognitively intact, received an anticoagulant (blood thinner to prevent blood clots) medication, and had diagnoses that included end-stage renal disease (kidney failure). Physician's orders for Resident 1, dated April 30, 2023, included an order for the resident to receive 2.5 milligrams (mg) of Eliquis (an anticoagulant) two times a day. A nursing note for Resident 1, dated December 27, 2023, revealed that the resident's Eliquis orders were put on hold due to surgery on December 29, 2023. Nursing staff were to check when the Eliquis was to be resumed after surgery was completed. A nursing note for Resident 1, dated December 29, 2023, at 7:30 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 observations and staff interviews, it was determined that the facility failed to ensure that medications were appropriately secured within the medication carts for one of four medication carts reviewed (Hall B) and failed to ensure that labeling of medication matched physician's orders for one of 29 residents reviewed (Resident 59). Findings include: Observations of a medication cart on Hall B on January 10, 2024, at 11:58 a.m. revealed that the first of four large drawers in the medication cart contained four unidentified, loose pills; the second large drawer contained three unidentified, loose pills; and the fourth large drawer contained two unidentified, loose pills that were unsecured and not in the pharmacy's packaging. Interview with Licensed Practical Nurse 2 at that time confirmed that the pills were loose in the bottom of the cart drawers and should not have been. Interview with the Director of Nursing on January 10, 2024, at 12:28 p.m. confirmed that there were unidentified loose medications in the drawers of the Hall B medication cart. Physician's orders for…

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

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food service safety by failing to ensure that dietary staff wore beard coverings that completely covered their beard during food handling. Findings include: The facility's dietary policy regarding personal hygiene, dated September 21, 2023, revealed that staff were to cover all hair and facial hair with restraint, either with a hairnet, cap, or hat. Observations in the kitchen on January 10, 2024, at 11:10 a.m. revealed dietary staff at the stove preparing chicken pot pie for the resident's lunch. Dietary Aide 4 was observed with approximately four to five inches of his beard not contained within the beard net. Interview with the Dietary Director on January 10, 2024, at 11:15 a.m. confirmed that Dietary Aide 4 did not have all of his beard covered with a restraint as he should have. Interview with Nursing Home Administrator on January 10, 2024, at 3:46 p.m. confirmed that Dietary Aide 4 should 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 the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending February 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 11, 2024, identified repeated deficiencies related to a failure to ensure quality of care and a failure to ensure labeling and storage of medications. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending February 8, 2023, revealed that the facility would complete…

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 proper hand washing techniques were used during medication administration for three of five residents observed (Residents 17, 59, 83). Findings include: The facility's policy regarding hand hygiene, dated September 21, 2023, indicated that all employees were to follow the hand washing procedure, which included hand sanitizing, before preparing or handling medications. Observations during the medication pass in B hall on January 9, 2024, at 1:20 p.m. revealed that Licensed Practical Nurse 3 prepared Resident 83's medications and administered them. Without sanitizing her hands she prepared and administered Resident 59's medications. She then went to Resident 17's room and without sanitizing her hands she prepared and administered her medications. Licensed Practical Nurse 3 then washed her hands in the sink and exited the resident's room. Interview with Licensed Practical Nurse 3 on January 9, 2024, at 1:20 p.m. confirmed that she should have sanitized…

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.