Third Avenue Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interviews, it was determined the facility failed to ensure that one resident out of 18 sampled (Resident 26) was afforded the right to participate in care and treatment decisions, to be fully informed of treatment, and to make choices about preferred treatment options. The findings include: Review of the clinical record revealed that Resident 26 was admitted to the facility on [DATE], with diagnoses to include osteoarthritis (a joint disease characterized by the breakdown of cartilage causing pain and stiffness), and chronic pain. A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 2, 2025, revealed that Resident 26 was severely cognitively impaired with a BIMS score of 15 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility for one resident (Resident 53) out of 13 residents sampled. Findings include: Review of the facility Restorative Nursing Services Policy last reviewed February 13, 2025, indicated residents who could benefit from the nursing restorative programs can be identified at the following times: on admission, when other assessment are required such as a Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care), from the 24-hour report and the change of shift report, at morning standup meeting, at care planning, and other resident-focused meetings, at risk management meetings such as behavior management, nutrition at risk, and during weekly restorative weekly reviews. If appropriate the resident will begin the restorative program. 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 observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of two medication carts observed (Teal Hall). Findings include: Review of the facility policy titled Medication Labeling and Storage last reviewed by the facility February 13,2025, indicated that multi-use vials that have been opened or accessed (e.g. needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. An observation of the medication cart located on Teal Hall unit on May 29, 2025, at 8:24 AM, in the presence of Employee 2 (Licensed Practical Nurse ) of the medication stored in the medication cart, revealed two (2) multi-dose insulin pens of Insulin Lispro ( a fast acting insulin medication used to lower blood sugar ) and Insulin Glargine (a long acting insulin medication used to lower blood sugar) that had been opened and available for use, but not dated when initially opened. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility investigative documentation, clinical records, and staff interviews it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses promptly assessed and evaluated a resident after a significant medication error occurred to assure the resident received necessary care and services timely for one resident (Resident 1) and failed to implement physician's orders for wound treatments for two residents (Resident 3 and 4) out of 12 sampled. Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to collect complete 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. 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 review of clinical records, and staff interview, it was determined that the facility failed to timely notify the physician and the resident's responsible party of medication error for one resident out of 12 sampled (Resident 1). Findings include: A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnosis to include Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills). A review of Resident 1's quarterly minimum data set (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 2, 2024 revealed a BIMS score of 3 (BIMS- brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 00- 07 equates to severe cognitive impairment). A review of a facility investigative report dated September 18, 2024 at 12:38 PM revealed on September 15, 2024, the resident was given a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, a facility investigative report, nurse competencies and staff interview, it was determined the facility failed to to ensure that licensed nursing staff possessed the skills and competencies necessary to assure administration of medications accurately and safely for one resident out of 12 sampled (Residents 1). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (1) undertake a specific practice only if the licensed practical nurse has the necessary…

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 pharmacy documentation, clinical records and staff interviews it was determined the facility failed to implement procedures to assure timely acquiring and administration of medications to one of 12 sampled residents (Resident 4). Findings include: A review of Resident 4's clinical record revealed the resident was readmitted to the facility on [DATE], with diagnoses which included malignant neoplasm of the vulva (cancer of the female genitals). A review of physician orders dated September 13, 2024, revealed the following orders: Oxycodone (narcotic pain medication) 5mg (milligrams) every 6 hours as needed for moderate to severe pain. Ativan (anti-anxiety medication) 0.5mg every 12 hours as needed for generalized anxiety disorder. A review of a pharmacy delivery slip dated September 17, 2024, revealed the resident's medications were not delivered to the facility until September 17, 2024, four days after the medication was ordered. The resident did not receive the medications as ordered due 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical records, select facility policy, facility investigative reports, and staff interview it was revealed the facility failed to assure that one of 12 residents reviewed were free of significant medication errors (Resident 1). Findings include: A review of a facility pharmacy policy, entitled General Dose Preparation and Medication Administration last reviewed April 30, 2024 revealed prior to the administration of medication facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, and the correct route, at the correct rate, at the correct time, for the correct resident. Further it is indicated the facility staff should verify the resident's identification (e.g. picture, armband, name). A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnosis to include Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for one of 12 sampled residents (Resident 1). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. According to the Title 49, Professional and Vocational Standards,…

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 clinical records and select facility policy review and staff interview, it was determined that the facility failed to timely respond to a resident's increased level of pain and provide an effective pain management to alleviate pain for one resident of 13 residents sampled (Resident 52). Findings include: Review of a facility policy entitled Pain Assessment and Management Protocol provided by the facility on July 31, 2024, indicated that any resident admitted to the facility would be assessed for pain and/or the potential for pain for the resident to reach and maintain his/her highest practicable level of physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The physician/provider will be notified of new onset of pain or significant increase in pain as appropriate. A review of Resident 52's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (is a medical…

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 observation and staff interview, it was determined that the facility failed to maintain a safe, sanitary, and orderly environment in the resident's main dining room area. Findings include: Observations of the resident's main dining room on [DATE], at 9:30 a.m., revealed four grey-pattered chairs with leather-like seats that appeared significant worn. Also, observed that the dining room windowpanes had significant debris and deceased bugs inside and the white colored blinds that covered the exit door window had cobwebs and live spiders adhered to the surface. Observed that the grey garbage inside of the resident's main dining room had splatter and debris adhered to the lid and the floor was sticky. Further observations of the resident's main dining room area on [DATE], at 12:30 p.m., revealed that the above observations continued. Interview with the Nursing Home Administrator on [DATE], at 1:39 p.m., confirmed the above observations and confirmed that the resident's dining area should be maintained in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy and investigative reports and staff interview, it was determined that the facility failed to implement procedures to identify and prevent potential misappropriation of resident property, medications, for one resident out of 13 sampled (Resident 49). Findings include: The facility policy for Abuse Protection, reviewed by the facility April 8, 2024, revealed, it is the policy of the facility to investigate all allegations, suspicions, and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown injury. Facility staff must immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in the policy. All allegations of abuse, neglect, involuntary seclusion, injuries of unknown source, and misappropriation of resident property must be reported immediately to the Administrator, Director of Nursing, and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interview, it was determined that the facility failed to timely develop and implement a person-centered care plan to meet one resident's current needs for two of 13 sampled resident (Resident 26). Findings including: Clinical record review revealed that Resident 26 was admitted to the facility on [DATE], with diagnoses to include dementia. Review of quarterly Minimum Data Set Assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 18, 2024, revealed that Resident 26 was severely cognitively impaired with a BIMS score (BIMS (Brief Interview for Mental Status) is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) of 0 and required assistance from staff for activities of daily living. An observation of Resident 26's room on July 30, 2024, at approximately 10:30 a.m., revealed the resident's bed was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to complete a discharge summary, which included a recapitulation of the resident's stay, the course of illness, corresponding treatment, discharge instructions, and a post-discharge care plan for one of three discharged resident records reviewed (Resident 23). Findings include: A review of the closed clinical record revealed that Resident 53 was admitted to the facility on [DATE], with diagnoses including MRSA infection, pneumonia, and heart failure, and discharged to home on May 25, 2024. A review of Resident 53's physician orders upon discharge revealed that the following medications were prescribed; amiodarone 200mg daily, amlodipine 5mg daily, calcitriol 0.25mcg weekly on Monday, Eliquis 5mg two times a day, furosemide 40mg daily, levothyroxine 75mcg daily, metoprolol succinate 50mg daily, and potassium chloride 10meq two times a day. Review of the closed record failed to provide evidence of disposition of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medication to one of 13 sampled residents (Resident 13). Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. Review of the clinical record revealed that Resident 13 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record and select facility policy review and staff interview, it was determined that the facility failed to clinically justify the use of a foley (indwelling) catheter for two of 4 sampled residents with catheters (Resident 7 and 24). Findings include: Review of Resident 7's clinical record revealed that he was admitted to the facility on [DATE], with diagnoses to have included dementia (is a term for a group of diseases and conditions that affect your thinking, memory, reasoning, personality, mood, and behavior), dysphagia (difficulty swallowing), and major depressive disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of a hospital urology consult dated February 24, 2024, revealed that Resident 7 had a urinary tract infection (UTI - is a sudden and severe inflammation of kidney due to a bacterial infection) due to use of a Foley catheter (is a device that drains urine from the bladder into a collection bag outside of the body when an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an effective individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of 13 residents reviewed (Resident 29). Findings include: A review of Resident 29's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include Alzheimer's disease (progressive brain disorder that affects memory, thinking, and behavior) A review of Resident 29's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 2, 2024, revealed the resident was severely cognitively impaired. A review of progress notes in the resident's clinical record dated from February 01, 2024 to July 30, 2024, revealed that the resident exhibited behaviors of spitting, striking out, biting, and agitation. The resident's current care plan, in effect…

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 clinical records and staff interviews, it was determined that the facility failed to ensure that a resident was free from unnecessary psychoactive drugs by failing to ensure the presence of clinical rationale for the continued use of an as needed psychotropic medication for one of five residents reviewed (Resident 29). Findings include: A review of Resident 29's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include Alzheimer's disease (progressive brain disorder that affects memory, thinking, and behavior) Review of Resident 29's clinical record revealed a physician's order for alprazolam (used to treat anxiety) tablet 0.25 MG give 1 tablet by mouth every 12 hours as needed for Anxiety with a start date of April 02, 2024, and no end date . Review of the June 2024 Medication Administration Records (MAR) revealed that the medication (alprazolam) was administered to the resident four times during the month of June 2024. Review of the July 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to follow-up with required dental services for one Medicaid payor source out of 13 residents sampled. (Resident 37). Findings include: Review of Resident 37's clinical record indicated that the resident was admitted to the facility on [DATE], and that the resident's payor source was Medicaid. Review of Resident 37's clinical record revealed documentation dated May 9, 2024, at 6:04 PM, which indicated that the mobile dental services had been running behind and that it was now too late to come to facility for dental checks and resident's two extractions. Stated they would be calling the facility to reschedule the day that they would be in to complete. provided by the facility indicated that the resident was last seen by a dentist on October 26, 2022. A review of Oral Hygiene Consult Sheet dated May 16, 2024, indicated that the resident had no dental complaints. Recommendations included to continue care, brush daily,…

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 resident sand staff, it was determined that the facility failed to maintain an effective pest control program. Findings include: Observations during an environmental tour of the facility on April 16, 2024, at approximately 11:30 AM, down the service entrance hallway in the presence of the Director of Nursing, revealed that the doors to the kitchen, dry storage room, and mechanical room were open. Further observation revealed that the door from the mechanical room leading to the outside of the building was also open to the outside, providing a means of entry for pests. Observation of the dietary dry storage room revealed that there were mice droppings on the floor and on a pest glue trap located beneath a metal shelving unit on the right-hand side of the room. The facility's pest control company invoice/report dated March 6, 2024, failed to include information related to services provided and/or results of any inspection. Review of the facility's pest control company invoice/report dated April 3, 2024, indicated that service to all rooms 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 observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observations during a tour of the dry storage room was conducted with the Director of Nursing on April 16, 2024, at approximately 11:30 AM, revealed the following unsanitary practices with the potential 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 observation, clinical record review and staff interview, it was determined that the facility failed to maintain an environment free of potential accident hazards to the extent possible on one of three resident hallways (Rooms 9-16). Findings include: Observations made during an environmental tour of the facility on April 16, 2024, at approximately 11 AM revealed an unattended, and unlocked, treatment cart in the hallway of the resident unit. Further observation of the treatment cart revealed that the second drawer was open, exposing the contents of prescription creams and/or ointments. The sixth drawer was also open and exposed treatment supplies used to perform treatments to residents. Observation of the top of the cart revealed a laptop, and packages of unopened curettes (tool with a sharp blade to remove nonviable skin). Observation further revealed residents were ambulating and self-propelling in wheelchairs in the hallway while the opened cart was left unattended. Interview with the Director of Nursing revealed that the facility's wound care consultant was performing…

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

Based on a review of clinical records and select facility reports and staff interview it was determined that the facility failed to assure that one resident out of six sampled was free from a significant medication error. (Resident 2). Findings include: A review of Resident 2's clinical record revealed that the resident had diagnoses that included dementia and hypertension. Further review of the resident's clinical record revealed that the resident required that her medications be crushed. A pharmacy consultant report dated October 24, 2023, identified that some of the resident's prescribed medications not recommended to be crushed per manufacturer guidelines. The pharmacist recommended changing Metoprolol succinate 25 mg (antihypertensive) to Metoprolol tartrate 12.5 mg two times a day (immediate release antihypertensive that may be crushed). The physician reviewed and accepted the pharmacist's recommendations on November 28, 2023. Review of a time sensitive pharmacy consultant report dated December 20, 2023, indicated that Resident 2 was receiving duplicate drug therapy. 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 a review of clinical records, information submitted by the facility and the facility's abuse prohibition policy and staff interviews, it was revealed the facility failed to timely report an injury of unknown origin, a fractured arm, and the results of the facility's completed investigation into possible resident abuse or neglect within 5 working days of the incident to the State Survey agency for one of four residents reviewed (Resident 2). Findings include: A review of facility policy titled, Abuse, neglect and misappropriation, reviewed by the facility August 30, 2023, revealed that the facility will not tolerate abuse, neglect, mistreatment and exploitation of residents and misappropriation of resident property by anyone. Facility staff must immediately report all such allegations to the administrator/abuse coordinator. The administrator/abuse coordinator will immediately begin an investigation and notify the applicable and local and state agencies in accordance with the procedures in this policy. The time frame for investigation is notes as, the investigation must be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility's abuse prohibition policy and procedures, facility provided documentation, and clinical records and interviews with staff it was determined that the facility failed to timely and thoroughly investigate an injury of unknown source to rule out abuse, neglect or mistreatment for one of the four residents sampled (Resident 2). Findings include: A review of facility policy titled, Abuse, neglect and misappropriation, dated as reviewed August 30, 2023, revealed that the facility will not tolerate abuse, neglect, mistreatment and exploitation of residents and misappropriation of resident property by anyone. Facility staff must immediately report all such allegations to the administrator/abuse coordinator. The administrator/abuse coordinator will immediately begin an investigation and notify the applicable and local and state agencies in accordance with the procedures in this policy. The time frame for investigation is notes as, the investigation must be completed within 5 working days…

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 clinical records, select facility reports and employee personnel files, and resident and staff interviews it was determined that the facility failed to assure that licensed and professional nursing staff possessed the necessary skills and competencies to accurately perform medication administration as prescribed to one resident out of four sampled (Resident 1). Findings included: Review of Resident 1's clinical record revealed admission to the facility on September 24, 2022, with diagnoses, which included cerebral vascular disease ( a stroke) with left sided hemiparesis. A review of a facility investigation report dated September 9, 2023, at 6:30 P.M. revealed that a licensed nurse administered the wrong medications to Resident 1, which the resident identified prior to ingestion. Resident 1, who resided in room [ROOM NUMBER] W, notified staff of the error and pills were removed. Nursing staff then provided Resident 1 the correct medications. Resident 1 reported that I was given 8 pills…

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.