King Of Prussia Skilled Nursing And Rehabilitation

Based on review of facility documents, and staff interview, it was determined that the facility failed to provide training on effective communication for four out of five staff members (Employee E3, Employee E4, Employee E5, Employee E6,). Findings include: Review of facility provided documents and training records revealed the following staff member did not have documented training on effective communication. Nurse Aide (NA) Employee E3 had a hire date of July 9, 2024, failed to have effective communication training between August 16, 2023, and August 15, 2024. Licensed Practical Nurse (LPN) Employee E4 had a hire date of June 25, 2024, failed to have effective communication training between August 16, 2023, and August 15, 2024. Registered Nurse (RN) Employee E5 had a hire date of July 9, 2024, failed to have effective communication training between August 16, 2023, and August 15, 2024. Dietary Aid Employee E6 had a hire date of July 29, 2024, failed to have effective communication training between August 16, 2023, and August 15, 2024. During an interview on August 15, 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 review of new hire personnel records and interviews, it was determined that the facility failed to provide training on Resident Rights for four out of five staff members (Employee E3, Employee E4, Employee E5, Employee E6, Employee E7). Findings include: Review of facility provided documents and training records revealed the following staff member did not have documented training on Resident Rights. Nurse Aide (NA) Employee E3 had a hire date of July 9, 2024, failed to have Resident Rights training between August 16, 2023, and August 15, 2024. Licensed Practical Nurse (LPN) Employee E4 had a hire date of June 25, 2024, failed to have Resident Rights training between August 16, 2023, and August 15, 2024. Registered Nurse (RN) Employee E5 had a hire date of July 9, 2024, failed to have Resident Rights training between August 16, 2023, and August 15, 2024. Dietary Aid Employee E6 had a hire date of July 29, 2024, failed to have Resident Rights training between August 16, 2023, and August 15, 2024. Interview conducted with the Staff Educator Employee E7 on August 15, 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 staff interviews and a review of facility training and orientation records, it was determined that the facility failed to provide training on the facility's abuse prohibition policy and facility specific procedures for one out of five new hires (Employee E6). Findings include: Review of Dietary Aid Employee E6's personnel record revealed he/she had a hire date of July 29, 2024. Further review of the personnel record failed to provide evidence that Dietary Aid E6 received training on abuse, neglect, and exploitation between August 16, 2023, and August 15, 2024. Interview conducted with the Staff Educator Employee E7 on August 15, 2024, at 12:45 p.m. reported she was unable to provide evidence the employees above received training regarding abuse, neglect, and exploitation. Interview on August 15, 2024 at 1:05 p.m. conducted with the Nursing Home Administrator (NHA) confirmed the above. 28 Pa Code 201.20(b) Staff Development 28 Pa Code 201.18(e)(1) Management 28 Pa Code 201.29(a)(c) Resident Rights

Based on review personnel records, and staff interview, it was determined that the facility failed to provide training on Infection Control for four out of five new hires (Employee E3, Employee E4, Employee E5, and Employee E6). Findings include: Review of facility provided documents and training records revealed the following staff member did not have documented training on Infection Control. Nurse Aide (NA) Employee E3 had a hire date of July 9, 2024, failed to have Infection Control training between August 16, 2023, and August 15, 2024. Licensed Practical Nurse (LPN) Employee E4 had a hire date of June 25, 2024, failed to have Infection Control training between August 16, 2023, and August 15, 2024. Registered Nurse (RN) Employee E5 had a hire date of July 9, 2024, failed to have Infection Control training between August 16, 2023, and August 15, 2024. Dietary Aid Employee E6 had a hire date of July 29, 2024, failed to have Infection Control training between August 16, 2023, and August 15, 2024. Interview conducted with the Staff Educator Employee E7 on August 15, 2024, at 12:45…

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 file for nursing assistants employed by the facility, it was determined the facility failed to ensure consistent in-service training and competencies were completed as required for one of five personnel files reviewed. (Employee E13) Findings include: Review of documentation of annual performance evaluations and logs of regular in-service training and competencies for Employee E13 failed to reveal ongoing training or annual evaluation. Interview with the Nursing Home Administrator, and Director of Nursing at 1:30 p.m., on August 15, 2024, confirmed that Employee E13 was the only nursing assistant employed with the facility for over twelve consecutive months. Further interview with the Nursing Home Administrator revealed that there was no documentation of nurse aide in-services at least twelve hours in a year, including dementia training, abuse prevention training, areas of weakness as determined in the nursing aide's performance review, facility assessment, special needs of residents and care of cognitively impaired residents for Employee E13. 28 Pa.…

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

Based on review of facility documents, employee education records, and staff interview, it was determined that the facility failed to provide training on behavioral health for four out of five staff members (Employee E3, Employee E4, Employee E5, and Employee E6) Findings include: Review of facility provided documents and training records revealed the following staff member did not have documented training on Behavioral Health. Nurse Aide (NA) Employee E3 had a hire date of July 9, 2024, failed to have Behavioral Health training between August 16, 2023, and August 15, 2024. Licensed Practical Nurse (LPN) Employee E4 had a hire date of June 25, 2024, failed to have Behavioral Health training between August 16, 2023, and August 15, 2024. Registered Nurse (RN) Employee E5 had a hire date of July 9, 2024, failed to have Behavioral Health training between August 16, 2023, and August 15, 2024. Dietary Aid Employee E6 had a hire date of July 29, 2024, failed to have Behavioral Health training between August 16, 2023, and August 15, 2024. Interview conducted with the Staff Educator Employee…

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 policy, clinical records, and staff interview, it was determined that the facility failed to thoroughly investigate an allegation of physical abuse for one of the 29 residents reviewed (Resident 54). Findings include: Review of the facility's policy titled Abuse Prohibition with review date of February 23, 2021, revealed the center will implement an abuse prohibition program through the identification of possible incidents or allegations that need investigations. The same policy revealed that upon receiving a report of suspected or alleged abuse, mistreatment, or neglect, the designee will initiate an investigation that focuses on whether abuse or neglect occurred and to what extent. The investigation will be thoroughly documented, ensure that documentation of witnessed interviews will be included. Review of Resident 54's diagnosis list includes Cerebrovascular Disease (stroke), and Anxiety disorder. Review of Resident 54's plan of care revealed resident was resistive and non-compliant with care. Review of Resident 54's Minimum Data Set (MDS- A…

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

Based on clinical record review and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for four of eight residents reviewed (Residents 17, 96, 332, and 333). Findings include: Rview of Resident 17's clinical record revealed the resident was transferred to the hospital on May 4, 2024, due to two episodes of vomiting and weakness. There was no documented evidence to indicate the facility provided a written notice to the Office of the State Long-Term Care Ombudsman regarding the resident's hospitalization. Review of Resident 96's clinical record revealed the resident was transferred to the hospital on August 10, 2024, due to a fall with laceration to the forehead. There was no documented evidence to indicate the facility provided a written notice to the Office of the State Long-Term Care Ombudsman regarding the resident's hospitalization. Review of Resident 332's clinical record revealed the resident was transferred to the hospital on April 5, 2024, for a clogged feeding tube and shoulder…

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 one of 32 residents reviewed (Residents 25). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), revealed that Section O0110 was to be completed with the resident's special treatments, procedures, and programs, and Section O0110 was to be coded for the use of Tracheostomy(a medical procedure that involves creating an opening in the neck in order to place a tube into a person's trachea, or windpipe) Care. Column (2) was to be checked if Tracheostomy Care was used while a resident of the facility within the last 14 days. Review of Resident 25's care plan, revised on July 11, 2024, indicated that the resident at risk for respiratory impairment related to tracheostomy. Physician's orders for Resident 25, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the minimum information necessary to properly care for a resident, for one of eight residents reviewed (Resident 333). Findings include: Review of Resident 333's clinical records revealed the resident was admitted into the facility on July 9, 2024, with medical diagnoses that include Seizures, Nontraumatic Intracerebral Hemorrhage (bleeding into the brain), Acute Respiratory Failure, Gastrostomy (creation of an artificial external opening into the stomach for nutritional support), Hepatic Encephalopathy (loss of brain function), Cirrhosis of Liver with Ascites (fluid in abdomen), and Rhabdomyolysis (breakdown of skeletal muscle). Review of Resident 333's physician orders dates July 9, 2024, to cleanse sacral wound with spray, apply calcium alginate and cover with foam dressing, Review of Resident 333's care…

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

Based on clinical record review and staff interview it as determined the facility failed to administer medications as ordered to one of 24 residents reviewed. (Resident 20) Findings Include: Review of Resident 20's physician orders revealed an order for Midodrine (increases blood pressure) 5 milligrams (mg) three times a day (TID) for hypotension (low blood pressure) hold for systolic blood pressure greater than 140. Review of Resident 20's Medications Administration Record (MAR) from August 1-13 2024 revealed the resident received the midodrine four times when the systolic blood pressure was above 140. Review of Resident 20's MAR for the entire month of July 2024 revealed the resident received the midodrine 13 times when the systolic blood pressure was above 140. Interview with the Director of Nursing on August 15, 2024 at 11:30 a.m. confirmed the medication was not administered as ordered by the physician. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of the facility's policy, clinical records review, and staff interview, it was determined the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for two of the 29 residents reviewed (Resident 54 and 127). Findings include: Review of the facility's policy titled Skin Integrity and Wound Management with a revised date of May 1, 2024, revealed that the licensed nurse will perform daily monitoring of wound dressing for the presence of complications and declines, implement skin/wound care guidelines, and implement special wound care treatments as indicated and ordered. Review of Resident 54's wound consult report dated July 29, 2024, revealed that the resident had a Stage 4 Pressure Ulcer (full-thickness skin and tissue loss) to the sacrum (tail bone) measuring 1.8 x 0.6 x 0.1 cm. The wound order recommendation was to cleanse the sacral wound with a normal saline solution and apply Calcium Alginate (wound dressing that absorbs excess moisture and promotes healing), and Puracol (wound product that contains collagen…

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

Based on Facility policy and procedure review, clinical record review and staff interview it was determined the facility failed to provide interventions to prevent a potential elopement for one of two residents reviewed. (Resident 101) Findings Include: Review of Facility policy and procedure titled Wandering, last revised May 1, 2022, revealed wandering behavior symptoms will be documented on the Behavior Monitoring and Intervention Flow Record or Behavior Tracking Form. Forms will be reviewed to determine triggers associated with the behavior and effectiveness of non-pharmacological interventions. Behavior symptoms will be addressed in the care/service plan. Review of Resident 101's progress notes revealed a social service entry dated July 26, 2024 at 2:17 p.m. stating, resident also reported that she tried to escape this joint and admitted to going into the staircase and attempt to walk upstairs. Further review of Resident 101's clinical record revealed there were no assessments completed to determine the residents risk for elopement and no care plan developed with interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy and procedure review, observations, and staff interview it was determined the facility failed to provide care and services for foley catheters for one of five residents reviewed. (Resident 20) Findings Include: Review of facility policy and procedure titled Catheter: Urinary-Justification for Use, last revised August 7, 2023, revealed Patients who have urinary catheters upon admission or subsequently receive one will be assessed for removal of the catheter as soon as possible unless the patients clinical condition demonstrates that catheterization is necessary. If the patients condition meets any of the indwelling catheter criteria, obtain a physician order, include in care plan. Observation of Resident 20 on August 12, 2024 at 9:30 a.m. revealed the resdient had a Foley Catheter (tube placed into the bladder to drain urine). Review of Resident 20's progress notes revealed a Nursing Clinical admission Notes dated June 19, 2024 at 2:46 p.m. stating the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's policy, clinical records review, and staff interview, it was determined the facility failed to appropriately monitor, provide appropriate interventions, and timely notify the physician of a significant weight change for two of 29 residents reviewed (Residents 85 and 127). Findings include: Review of the facility's policy titled Weights and Heights last reviewed on June 15, 2022, revealed that patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. The purpose was to obtain baseline weight and identify significant weight changes. Review of Resident 85's dietary notes dated June 24, 2024, revealed the resident with a diagnosis of Progressive Supranuclear Ophthalmoplegia (movement disorder that occurs from damage to certain nerve cells in the brain). The same note revealed resident was on NPO (nothing per mouth), had a gastrostomy tube (medical device used to provide nutrition to people who cannot obtain nutrition by mouth), 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 Clinical record review and staff interview it was determined the facility failed to provide enteral nutrition (feeding delivered through a feeding tube) as ordered by the physician for one of eight residents reviewed. (Resident 332) Findings include: Review of Resident 332's clinical record revealed the resident admitted from the hospital on March 13, 2024, with medical diagnoses that include history of Traumatic Brain Injury, Gastrostomy (artificial external opening into the stomach for nutritional support), Epilepsy (recurring seizures), and Encephalopathy (disease of the brain). Review of Resident 332's physician orders revealed an order dated July 19, 2024, for Osmolite 1.5 @100 ml/hr. X 16 hrs. for TV (total volume) of 1600, FWF (amount of liquid that is water) 70 ml x 16 hrs for 1120 TV TF +FWF=2340 water total. Review of Resident 332's Medication Administration Record (MAR) for the months of July and August 2024 revealed there were no days where it was documented the resident received a total of 1600 ml per day as ordered by the physician. Interview with the 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 clinical record review, facility policy and procedure review and staff interview it was determined the facility failed to ensure residents did not receive unnecessary psychotropic medications for two of six residents reviewed. (Residents 65 and 101) Findings Include: Review of facility policy and procedure titled Behaviors: Management of Symptoms last reviewed July 1, 2024 revealed, when medication sis ordered for behavior symptoms completed the Psychotropic/Therapeutic Medication use evaluation when a patient is newly prescribed psychotherapeutic medication and then quarterly. Complete the Abnormal Involuntary Movement Scale (AIMS) per nursing schedule for patient receiving antipsychotic medications. Review of Resident 65's progress notes revealed a psychiatrist entry dated July 5, 2024 with a plan for the residents current Depakote (mood stabilizer) 250 milligrams twice a day to be discontinued and a new order to increase the Depakote 250 milligrams to three times a day. Review of Resident 65's current physician orders revealed the resident was still receiving Depakote…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, facility policy and procedure review and staff interview it was determined the facility failed to date and label insulin pens on two medications carts and reconcile medications on discharge for one of three residents. (Resident: 131) Findings Include: Review of facility policy and procedure Insulin Pens, last reviewed July 1, 2024, revealed Insulin Pens will be clearly labeled with the patient name, physician name, date used; a new pen must be ordered from the pharmacy. Observations of the medication cart 1 on the skilled nursing unit on August 15, 2024 at 9:15 a.m. revealed four insulin pens that were opened and being used but had no date of when they were opened or when they were to be discarded. Interview with Licensed Nursing Employee E10 at the time of the observation confirmed that these pens were opened and in use and should have been dated with the date they were first used. Observations of the medication cart 2 on the skilled nursing unit on August 15, 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 clinical record review and staff interview it was determined the facility failed to obtain laboratory studies as ordered for one of 24 residents reviewed. (Resident 20) Findings Include: Review of Resident 20's physician orders revealed an order dated August 1, 2024 for a CBC (comprehensive blood count- count of all the cells in the blood) and a CMP (comprehensive metabolic panel- a routine blood test that measures 14 different substances in a sample of your blood). Review of resident 20's Results for laboratory studies revealed these lab studies were not completed as ordered. Review of Resident 20's physician orders revealed an order dated July 5, 2024 for a CBC and a CMP and a tacrolimus level (measures the amount of drug in the blood to determine whether concentrations have reached therapeutic levels). Review of resident 20's Results for laboratory studies revealed these lab studies were not completed as ordered. Review of Resident 20's physician orders revealed an order dated June 24, 2024 for a CBC and a CMP and a tacrolimus level. Review of resident 20's Results for…

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

Based on clinical record review and staff interview it was determined the facility performed laboratory studies without a physician order for one of 24 residents reviewed. (Resident 24) Findings Include: Review of Resident 20's laboratory results revealed the results for a Magnesium level (blood test to determine the amount of magnesium in the blood), BMP (Basic Metabolic Panel- a test that measures eight different substances in your blood) and a CBC (comprehensive blood count- count of all the cells in the blood) completed on August 12, 2024. Review of resident 20's physician orders revealed there was no order for these laboratory studies. Review of Resident 20's laboratory results revealed the results for a CBC completed on June 24, 2024. Review of resident 20's physician orders revealed there was no order for this laboratory study. Review of Resident 20's laboratory results revealed the results for CMP (a routine blood test that measures 14 different substances in a sample of your blood) and a CBC completed on June 21, 2024. Review of resident 20's physician orders revealed there…

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

Based on clinical record review, observations, and staff interviews, it was determined that the facility failed ensure infection control management was implemented during a tracheostomy care and failed to follow policy related transmissions-based precautions and use of personal protective equipment for two of 32 sampled residents. (Resident 4 and Resident 85). Findings include: Review of Resident 4's clinical record revealed an active order for indwelling catheter (a tube inserted into a bladder to drain urine) with a start date of January 15, 2024. Observations conducted of the Resident 4 on August 12, 2024, confirmed Resident 4 had an indwelling catheter. Additional observations of Resident 4 revealed an absences of Enhanced Barrier Precaution signs located in Resident 4's room or outside his room. Additional review of Resident 4's clinical record failed to reveal an order for Enhanced Barrier Precautions. Interview conducted with the Director of Nursing (DON) on August 13, 2024, at 1:55 a.m. confirmed the facility failed to place Resident 4 on Enhanced Barrier Precautions related…

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 interviews, it was determined the facility failed to ensure treatment with dignity and respect for one of five residents observed (Resident R1) Findings include the following: Review of Resident R1's clinical record including medical diagnoses revealed diagnoses including but not limited to Dementia, Diabetes II, Peripheral Vascular Disease, muscle disorder, Peripheral Vascular Angioplasty status, Chronic Kidney Disease, Hypertension, Hyperlipidemia, and Anemia. Review of Resident R1's clinical record including MDS assessments revealed resident's BIMs score was 99 which indicates severe impaired cognitive function. Observation conducted on April 16, 2024, at 10:56 am, revealed Resident observed from the hallway laying without clothes on in bed. Resident R1's door and privacy curtain were both open, revealing Resident R1's body to anyone who walked past the room. A female housekeeper was mopping the room at the time of observation. This surveyor inquired if the resident was naked, the housekeeper stated that she was. As this surveyor turned to get staff to…

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 interviews with staff it was determined that the facility failed to provide hot water for all residents residing in the facility for two of two days observed, April 16, 2024, and April 17, 2024. Findings include the following: Tour of facility on April 16, 2024, at 11:45 am., revealed the shower rooms and bathrooms were not receiving sufficient hot water for comfort. Interview with Maintenance staff, Employee E confirmed the hot water temperatures were approximately 98 degrees in the shower rooms, bathrooms, and kitchen. Employee E6 indicated the hot water temperatures will be increased but the temperatures may take a few hours to circulate throughout the facility. Tour of the facility of April 17, 2024, at 1:00 pm., revealed no water in the shower rooms and low flowing water in the bathrooms. Interview conducted with maintenance staff, Employee E6, revealed a recent water pipe burst caused the need to turn the water off. Employee E6 provided documenation from the repair company indicating their estimated time of arrival was April 17, 2024, at 3:30 pm.…

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 observations and staff interview, it was determined that the facility failed ensure three medication carts were locked and secured out of six medication carts observed. Findings include: Observations conducted within the facility on [DATE], at 11:16 am., revealed three medication carts were unlocked. Observations of medication cart located behind the nurses' station and contained various creams, ointments, bandages, gauge, and powders. Observation conducted within the faccility of two other medication carts located adjacent to the nurses' station, revealed one contained bottles of medications, which was later established to be expired house medications, the other was labeled emergency cart and contained medical supplies but no medications. Observations conducted on [DATE], at 11:35 pm., accompanied by the Director of Nursing (DON) revealed the Director of Nursing was unaware of the unlocked medication carts. Interview and observations with the DON confirmed the house medications were expired and should…

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

Based on clinical record review and staff interview it was determined the facility failed to follow physician orders for one of 3 residents reviewed. (Resident R1) Findings Include: Review of Resident R1's physician orders revealed an order dated January 20, 2024 for Oxycodone (narcotic pain reliever) 10mg, give one tablet by mouth every 8 hours as needed for severe pain. Review of Resident R1's Medication Administration Record for January 2024 revealed Resident R1 received a dose on January 27, 2024 at 4:29 p.m. and the next dose administered was on January 28, 2024 at 8:30 p.m. Review of Resident R1's Progress Notes revealed a nursing entry on January 29, 2024 at 9:26 a.m. stating Resident insisted that he wanted his pain medication and charge nurse told him that he could offer him Tylenol extra strength as ordered but was waiting on pharmacy to deliver his oxycodone medication in an hour or so. Review of a list of medications the facility has in the PYXIS drug dispensing system revealed nine tablets of Oxycodone 5mg. Interview with the Director of Nursing on January 29, 2023 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with residents and staff, it was determined that the facility failed to provide a clean and homelike environment on one of four nursing units. Findings included: Observations of the Arcadia unit on September 27, 2023, at 10:14 a.m. in room [ROOM NUMBER] revealed that the over-the-bed table by the door was covered with a coating of what looked like dried milk and the laminate on the table had peeled off in some spots exposing the particle board underneath. The wall at the foot of the beds had a large area of wall paper (approximately twenty-four inches tall by twelve inches wide) that was torn away and hanging loose. The room had an odor of urine, and the floor was dirty with a build up of grime, food and paper debris. The entire end wall of the resident's closet, approximately twenty-four inches wide, extending upward approximately eighteen inches, had signs of water damage. The wall was warped and the base board had pulled away from the wall in several spots exposing the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for 13 of 56 residents reviewed (Residents 18, 24, 27, 32, 33, 54, 64, 71, 84, 95, 101, 103, 112). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 18, dated August 8, 2023, indicated that the resident was understood and able to understand others, required supervision with personal hygiene needs, assist of one with transfers, bathing did not occur, and it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. Bathing documentation for August 1 through September 26, 2023, indicated that Resident 18 was to receive a shower/bath during the day shift on Monday and Thursdays. There was no documented evidence that the resident received a shower during the month of August. Documentation also revealed…

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

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for four of 56 residents reviewed (Residents 23, 29, 88, 96). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated August 16, 2023, revealed that the resident was cognitively impaired and required assistance from staff for daily care needs. Physician's orders for Resident 23, dated February 16, 2023, included an order for the resident to receive 25 milligrams (mg) Hydralazine (blood pressure medication) if her systolic (top number) blood pressure is greater than 180 two hours after her Lisinopril (blood pressure medication) was administered. Resident 23's Medication Administration Record (MAR) for August 2023 revealed that the resident's blood pressure was 181/95 on August 12, 190/62 on August 16, and 189/73 on August 27. However, there was no indication that the staff rechecked the resident's blood pressure two hours after the…

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

Based on clinical record reviews 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 one of 56 residents reviewed (Resident 27). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated July 13, 2023, revealed that the resident was cognitively intact and required extensive assistance from staff for her daily care needs. The resident's weight records revealed that she experienced a 12.08 percent (31.6 pound) (significant) weight loss in one month when his weight dropped from 261.6 pounds on May 20, 2023, to 230.0 pounds on June 28, 2023. There was no documented evidence that the physician was notified about the resident's significant weight loss. A dietary note for Resident 27, dated June 28, 2023, revealed that the resident was ordered daily weights to trend weight loss. There was no documented evidence that Resident 27's daily weights were obtained since ordered on June…

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 residents who were receiving tube feedings received appropriate treatment and services to prevent complications for one of 56 residents reviewed (Resident 79). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 79, dated August 27, 2023, revealed that the resident was cognitively impaired, required extensive assistance for daily care needs, and had a feeding tube. Physician's orders for Resident 79, dated August 22, 2023, included an order for the resident's feeding tube to be checked for placement every day and that she receives 1150 milliliters (ml) of Jevity 1.5 (type of liquid feeding given through a tube) formula every day. A care plan for Resident 79, dated August 21, 2023, indicated that the resident had a need for a feeding tube related to a swallowing impairment and that it should be checked for placement and residuals (amount of fluid/contents in the…

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

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that respiratory care was provided as ordered for one of 56 residents reviewed (Resident 29). Findings include: A quarterly MDS assessment for Resident 29, dated August, 18 2023, revealed that the resident was cognitively intact, had a tracheostomy (surgically-created airway in the windpipe), received tracheostomy care, and had diagnoses that included cancer of the tongue. Physician's orders, dated December 10, 2018, included an order for the staff to provide tracheostomy care every shift. A care plan, dated October 9, 2020, indicated that trach care was to be provided per the protocol. Resident 29's Treatment Administration Record (MAR) for July, August, and September 2023 revealed that tracheostomy care was not provided every shift as ordered on July 9, 13, 14, 17, 18, and 19; August 3, 6, 11, 14-17, 20, 21, 23, 25, 28, 30, 31; and September 1, 3, 6, 7, 9, 11-13, 15, 18, 20, 22, 24-26, 2023. Observations of Resident 29 on September 27, 2023, at 10:30 a.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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications, by failing to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of as needed antianxiety medications for one of 56 residents reviewed (Resident 101). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 101, dated August 14, 2023, indicated that the resident was cognitively intact, had no behavior symptoms, and required assistance from staff for her daily care needs. The resident's care plan, dated August 20, 2023, revealed that staff were to keep her busy with desirable activities. There were no interventions listed to attempt prior to administering antianxiety or antidepressant/sedative medication. Physician's orders for Resident 101, dated August 9, 2023, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (an antianxiety medication) every…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures. Findings include: The facility's food handling policy, dated May 1, 2023, revealed that cold foods are to be maintained at 40 degrees Fahrenheit (F) or below. If the food temperature rises above 40 degrees F, return to refrigerator and re-chill to 40 degrees F. Hot beverages, such as coffee, tea and hot chocolate are brewed and held at temperatures of 160-185 degrees F. Interview with Resident 11 on September 27, 2023, at 11:22 a.m. revealed that the food was terrible and the coffee was never hot. Interview with Resident 27 on September 27, 2023, at 12:32 p.m. revealed that the food was not good and the meat was hard to chew. Interview with Resident 42 on September 27, 2023, at 10:15 a.m. revealed that the food was terrible. Interview with Resident 50 on September 27, 2023, at 12:30 p.m. revealed that the food is always cold, 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 policies, observations, and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards of food service safety by failing to properly label and date stored foods and maintain a sanitary environment in the kitchen. Findings include: The facility's policy regarding food storage, dated May 1, 2023, revealed that foods in dry storage are to be in closed, labeled and dated containers; no open boxes or bags. For products that have been opened but not fully used, a use by date is included on the label. An initial tour of the kitchen on September 27, 2023, at 8:22 a.m. with Food Service Director 11 revealed that the floor was dirty with a build up of grime, the coffee machine drip tray had build up of dried coffee as well as dried splashes on the machine, a large bin of flour and sugar with a build up of grease and grime as well as drip stains on the lids and outsides of the containers, and a rack containing two large trays of bananas that were dark brown/black. Observations in the dry storage room 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 resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 56 residents reviewed (Resident 64). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 64, dated August 21, 2023, revealed that the resident was cognitively intact, required extensive assistance with daily care needs, and had diagnosis that included muscle weakness and abnormal posture. Physician's orders for Resident 64, dated August 15, 2023, included an order for the resident's left elbow to be cleansed with normal saline, a small amount of thera-honey (medical grade honey used in the treatment of wounds) applied to it, and then a foam dressing applied daily. Review of the Treatment Administration Record (TAR) for Resident 64, dated September 2023, revealed documentation that the resident was receiving the ordered treatment to her left elbow daily on September 2-3, 5-9, and 11-27, 2023.…

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

Based on review of facility policies and staff training records, as well as staff interviews, it was determined that the facility failed to provide annual abuse training for two of five employees (Licensed Practical Nurse 15, Registered Nurse 16). Findings include: The facility's abuse policy, undated, indicated that each resident had the right to be free from abuse, neglect, misappropriation of property, and exploitation. All facility staff were to be educated through orientation and a minimum of annually. A list of staff provided by the facility revealed that Licensed Practical Nurse 15 was hired on February 13, 2019. However, there was no documented evidence that Licensed Practical Nurse 15 received annual abuse training from February 13, 2022, through February 13, 2023. Registered Nurse 16 was hired on June 29, 2019. However, there was no documented evidence that Registered Nurse 16 received annual abuse training from June 29, 2022, through June 29, 2023. Interview with the Payroll Director (covering for the Human Resource Director) on September 29, 2023, at 4:13 p.m. confirmed…

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

Based on review of policies and employee files, as well as staff interviews, it was determined that the facility failed to implement its written abuse prevention policies, by failing to ensure that reference checks were obtained prior to hire for one of five employee files reviewed (Nurse Aide 12). Findings include: The facility's policy regarding abuse prohibition, undated, indicated that the facility would screen potential employees for a history of abuse, neglect, or mistreating residents, including attempting to obtain information from previous employers and/or current employers and checking with appropriate licensing boards and registries. The personnel file for Nurse Aide 12 revealed a hire date of July 13, 2023. There was no documented evidence that reference checks from previous or current employers were obtained prior to the employees' start date. Interview with the Payroll Director (covering for the Human Resource Director) on September 29, 2023, at 4:13 p.m. confirmed that they were not able to provide any evidence that employment reference checks were obtained prior to…

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 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 time frame for nine of 56 residents reviewed (Residents 8, 22, 23, 24, 27, 28, 49, 50, 51). 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 assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to have a completion date (Section Z0500B) that was no later than the ARD plus 14 calendar days. A quarterly MDS assessment for Resident 8 had an ARD of July 13, 2023. There was no previous quarterly or comprehensive MDS assessment 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed and implemented for one of 56 residents reviewed (Resident 106). Findings include: The facility's policy regarding baseline care plans, undated, revealed that the center must develop and implement a baseline person-centered care plan with 48 hours of admission/readmission for each patient/resident that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 106, dated September 20, 2023, revealed that the resident was admitted from the hospital on September 14, 2023, was understood, could understand, and required extensive assistance from staff for his daily care tasks. Physician's orders for Resident 106, dated September 14, 2023,…

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

Based on review of policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs for two of 56 residents reviewed (Residents 88, 95). Findings include: The facility's current policy for Person-Centered Care Plans indicated that a comprehensive, individualized care plan for each resident will be developed within seven days of the completion of the required comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) and the care plan will be reviewed and revised after each assessment. An annual MDS assessment for Resident 88, dated, August 2, 2023, revealed that the resident was cognitively intact, was independent with personal care needs, and had diagnoses that included diabetes, renal (kidney) failure, and deep vein thrombosis (blood clot). Physician orders for Resident 88, dated July 28, 2023, included for the resident to receive sliding scale (insulin dose varies based on blood…

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 a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 56 residents reviewed (Resident 84). Findings include: The facility's current policy for person-centered care plans indicated that care plans would be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 84, dated August 7, 2023, indicated that the resident was usually understood and could usually understand others, required extensive assistance for personal hygiene needs, had diagnoses that included dementia and generalized muscle weakness, and was receiving hospice care. A review of care plans for Resident 84, dated October 21, 2022, included that the…

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

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for one of 56 residents reviewed (Resident 81). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 81, dated August, 24 2023, revealed that the resident was cognitively intact, required extensive assistance to total dependence on staff for daily care needs, and had a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle). Physician's orders, dated August 7, 2023, included an order for the sacrum (area at the lower end of the spine) to be cleansed with normal saline solution (mixture of salt and water), packed with gauze soaked in Vashe (wound cleanser), and covered with a foam dressing daily and as needed. Physician's orders, dated September 18, 2023, included an order for gauze-soaked acetic acid (used to prevent wound infections) applied to the wound bed of the sacrum and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for two of 56 residents reviewed (Residents 23, 41). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated August 16, 2023, revealed that the resident was cognitively impaired and required assistance from staff for daily care needs, including mobility on and off the unit. Observation of Resident 23 on September 28, 2023, at 12:21 p.m. revealed that the resident was sitting in a wheelchair while being transported to her room by Licensed Practical Nurse 4. There were no footrests on her wheelchair to prevent her feet from dragging during the transport. An interview with Licensed Practical Nurse 4 on September 28, 2023, at 12:27 p.m. revealed that the facility does not keep foot rests on Resident 23's wheelchair and she 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.

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 a physician performed the initial comprehensive visit with the resident and was seen by the physician at least once every 30 days for the first 90 days after admission for one of 56 residents reviewed (Resident 102). Findings included: A nursing note for Resident 102, dated March 18, 2023, revealed that the resident was admitted to the facility. Resident 102's clinical record revealed that he was sent out to the hospital and admitted to the hospital on [DATE], and that he was readmitted to the facility on [DATE]. Resident 102's clinical record revealed that his initial physician visit was completed by the Certified Registered Nurse Practitioner (CRNP - a registered nurse who has advanced education and clinical training in a health care specialty area) and not by the attending physician. Resident 102's clinical record revealed that he was seen by the CRNP again on March 31, 2023, and April 5 and 7,…

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 Aides 6, 7, 8). Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire, annual performance evaluations for Nurse Aides 6, 7 and 8 were due between March 27 and May 11, 2023. As of September 29, 2023, there was no documented evidence that annual performance evaluations were completed as required for Nurse Aides 6, 7 and 8. Interview with the Payroll Director (covering for the Human Resource Director) on September 29, 2023, at 4:13 p.m. confirmed that he could not provide evidence that annual performance evaluations were completed as required for Nurse Aides 6, 7 and 8. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(a)(c) Staff development.

Based on review of 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 56 residents reviewed (Resident 84). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 84, dated August 7, 2023, indicated that the resident was usually understood and could usually understand others, required extensive assistance for personal hygiene needs, had diagnosis that included dementia and generalized muscle weakness, and was receiving hospice care. Physician's orders for Resident 84, dated August 4, 2023, included an order for the resident to receive 25 milligrams (mg) of Tramadol (a controlled pain medication) every six hours as needed for pain. Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 84 for August and September 2023 indicated that a dose of Tramadol was signed out on August 4 at 10:30 a.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 review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary drugs that were used for a longer duration than what was ordered by the physician for one of 56 residents reviewed (Resident 81). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 81, dated August, 24 2023, revealed that the resident was cognitively intact, had a pressure ulcer, and received an antibiotic medication. A nursing note for Resident 81, dated August 17, 2023, at 3:11 p.m. revealed that the resident had a Stage 4 pressure ulcer to her sacrum (area located at the end of the spine) that had a copious (large) amount of sero-purulent (watery drainage containing pus) drainage and a strong, foul odor. The Certified Registered Nurse Practitioner (CRNP-registered nurse with specialized training) was notified and an order was received for Keflex (antibiotic). Physician's orders, dated August 17, 2023, included an order for 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 and staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors for two of 56 residents reviewed (Residents 29, 88). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated August, 18 2023, revealed that the resident was cognitively intact, received an anti-psychotic medication, and had diagnoses that included schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). Physician's orders for Resident 29, dated May 24, 2023, included an order for the resident to receive 1 milliliter (mL) of 100 milligrams/mL of haldol decanoate (used to treat schizophrenia) one time a day every 21 days. The resident's care plan, dated May 17, 2021, indicated that the resident had diagnoses that included schizophrenia and his medications were to be administered as ordered by the physician. Resident 29's 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 review of facility documentation and staff interviews, it was determined that the facility failed to ensure that the Facility Assessment was completed, and reviewed and revised, as needed, at least annually. Findings include: Review of facility documents revealed that there was no documented evidence that a Facility Assessment was completed or reviewed and revised, as needed, at least annually. An interview with the Nursing Home Administrator on September 29, 2023, at 3:25 p.m. confirmed that there was no evidence of a completed Facility Assessment. 28 Pa. Code 201.18(e) Management.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for three of 56 residents reviewed who were receiving hospice services (Residents 40, 84, 95). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated August 3, 2023, indicated that the resident was cognitively impaired, was dependent on staff for personal hygiene needs, had a diagnosis of dementia, and was receiving hospice care (end-of-life services). Physician's orders for Resident 40, dated September 2, 2022, included an order for the resident to be evaluated and treated by hospice. Care plan for Resident 40, dated September 6, 2022, indicated that the resident was receiving hospice services with Heartland Hospice. A quarterly annual MDS assessment for Resident 84, dated August 7, 2023, indicated that the resident was usually understood and could usually…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending November 9, 2022, and a complaint investigation survey ending April 5, 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 September 29, 2023, identified repeated deficiencies related to Medicaid/Medicare liability notices, care plan timing and revision, the failure to provide quality of care, treatment and services to prevent pressure ulcers, free from accident hazards, nutrition and hydration, and records…

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 documentation and staff interview, it was determined that the facility failed to ensure that the Quality Assurance Committee met quarterly for two of three quarters reviewed (first and second quarter 2023). Findings include: Review of Quality Assurance Committee sign-in sheets revealed no evidence that the facility held quarterly meetings in 2023 prior to September 27, 2023. Interview with the Director of Nursing on September 28, 2023, at 4:00 p.m. confirmed that there was no documented evidence of quarterly quality assurance meetings being held in the first and second quarter of 2023. 28 Pa. Code 201.14(a) Responsibility of licensee

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 water management policy was implemented for the detection and/or prevention of Legionella within the facility's water systems. Findings include: The facility's policy regarding Legionnaires' Disease (a severe form of pneumonia), undated, revealed that appropriate infection control, environmental decontamination, and prevention measures will be followed for the prevention and management of legionella (Legionnaires' Disease). However, there was no documented evidence that the facility conducted a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system; implemented a water management program that considered the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE - an American professional association seeking to advance heating, ventilation, air conditioning and refrigeration systems design and construction)…

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 and staff interviews, it was determined that based on nurse aides' hire dates, the facility failed to ensure that nurse aides completed at least 12 hours of inservice education annually for three of three nurse aides reviewed (Nurse Aides 6, 7, 8). Findings include: Nurse aide education records revealed that based on their hire dates, Nurse Aides 6, 7, and 8 did not have at least 12 hours of education annually as follows: Nurse Aide 6's hire date was April 19, 2022, and inservice records revealed that she had 0.0 hours of education between April of 2022 and April of 2023. Nurse Aide 7's hire date was May 11, 2022, and inservice records revealed that she had 0.0 hours of education between May of 2022 and May of 2023. Nurse Aide 8's hire date was March 27, 2006, and inservice records revealed that she had 0.00 hours of education between March of 2022 and March of 2023. Interview with the Payroll Director (covering for the Human Resource Director) on September 29, 2023, at 4:13 p.m. confirmed that the above-listed nurse aides did not have evidence of…

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

Based on clinical record review and resident interview, it was determined that the facility failed to ensure residents received prescribed insulin timely for one of six residents reviewed (Resident R1). Findings include: Review of resident R1's clinical record revealed the following diagnosis: Type 2 Diabetes Mellitus without complications (condition results from insufficient production of insulin, causing high blood sugar). Interview with Resident R1 on September 1, 2023 at approximately 10:45 a.m. revealed resident retires for the evening around 8:00 p.m. Resident R1 stated that he/she receives the insulin medication later in the evening but is to be given the medication at bedtime. Review of R1's clinical record revealed a physician's order as follows; Levemir Solution 100 UNIT/ML (Insulin Detemir) Inject 18 unit subcutaneously at bedtime for DM. Review of R1's eMAR (electronic medication administration record) revealed R1 insulin medication was scheduled for administration at 8 p.m. Additional review of the eMAR revealed R1 received his/her insulin medication was administered 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.