Armstrong Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documents, and staff interviews, it was determined that the facility failed to report an allegation of neglect within 24 hours to the local state field office for one of two residents (Resident R1).Findings include: Review of facility's policy dated 7/1/25, Abuse, Neglect, and Exploitation stated it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse and neglect. Neglect means failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within a specific timeframe; immediately, but no later than two hours after the allegation is made, if the events that cause the allegation…

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 documents, facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services needed for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of five residents (Resident R1).Findings include: Review of facility Bowel Routine Policy last reviewed 7/1/25, indicated each resident will have routine bowel elimination. The purpose is to address the resident's individual needs with respect to routine bowel movements, initiate appropriate strategies and interventions, and monitor and evaluate resident outcomes. Give Milk of Magnesia 30 ml if no bowel movement in 72 hours (Day 3 without a bowel movement), if ineffective give Dulcolax Suppository. Administer fleet enema if Dulcolax Suppository is ineffective. Call physician if fleet enema is ineffective. Review of Residents R1's admission record indicated the resident was admitted on [DATE], with diagnoses of…

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

Based on review of facility policy, personnel records and staff interviews it was determined that the facility failed to complete annual performance evaluations for five of five nurse aides (NA) (NA Employees E4, E5, E6, E7, and E8).Findings include: Review of NA Employee E4's personnel record indicated a hire date of 9/19/11. Review of NA Employee E5's personnel record indicated a hire date of 9/21/18. Review of NA Employee E6's personnel record indicated a hire date of 2/26/23. Review of NA Employee E7's personnel record indicated a hire date of 8/27/23. Review of NA Employee E8's personnel record indicated a hire date of 10/2/23. Review of personnel records did not include an annual performance evaluation based on the date of hire for NA Employees E4, E5, E6, E7, and E8. During an interview on 12/9/25, at 1:57 p.m. Human Resources Employee E10 confirmed that the facility failed to complete annual performance evaluations for five of five nurse aides as required. 28 Pa Code: 201.14 (b) Responsibility of licensee28 Pa Code: 201.18 (b)(1)(3) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications and/or biologicals in three of five medication rooms (Second Floor (2C) Medication Room, Third Floor (3A) Medication Room, and Third Floor (3C) Medication Room) and failed to properly store medication in two of three medication carts (3BC Medication Cart and 2BC Medication Cart). Findings include: Review of facility policy Medication Storage dated [DATE], indicated that medications will be stored in the medication rooms according to the manufacturer's recommendations. All medications rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed. Review of facility Insulin Storage policy dated [DATE], indicated that insulin must be stored securely in a locked area. Follow specific instructions for opened insulin vials/pens. Often good…

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 financial documents, interviews with residents, resident's families, and staff it was determined that the facility failed to pay bills in a timely manner.Findings include: Review of the Nursing Home Administrator job description indicated: position purpose: leads, guides, and directs the operations of the healthcare facility in accordance with local, state, and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents. Resident R57 was admitted to the facility on [DATE]. Review of Resident R57 Minimum Data Set (MDS - a periodic assessment of resident needs) dated 11/14/25, indicated diagnosis of cerebral palsy (group of condition that affect movements and posture. I caused by damage that occurs to the developing brain, most often before birth) anxiety disorder (involve repeated episodes of sudden feelings of intense anxiety and or fear or terror), and abnormalities of gait (abnormal walking pattern). During 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 review of facility policies, review of clinical record, observations, and staff interviews, it was determined that the facility failed to maintain proper infection control practices related to failing to use Personal Protective Equipment (PPE) appropriately in Droplet Isolation (a type of isolation that requires a gown, gloves, N95 (a respirator mask), and eye protection, which created the potential for the cross-contamination and the spread of diseases and infections for four out of four resident rooms (Rooms 301, 304, 305, and 312), failed to clean residents rooms appropriately after isolation was discontinued for three of three rooms (rooms [ROOM NUMBER]), and failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionnaires (an infection of the lungs caused by bacteria, commonly spread by water) for 12 of 12 months.Findings Include:Review of facility Infection Prevention and Control Risk Assessment Procedure policy dated 10/13/25,…

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 documents, and staff interview, it was determined that the facility failed to provide training on Effective Communication for five of seven staff members (Registered Nurse (RN) Employee E3, Nurse Aide (NA) Employees E5, E6, E8, and Licensed Practical Nurse (LPN Employee E9).Findings include: Review of facility policy Training Requirements dated 8/13/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum…

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 documents, and staff interview, it was determined that the facility failed to provide training on Resident Rights for six of seven staff members (Nurse Aide (NA) Employee E4, NA Employee E5, NA Employee E6, NA Employee E7, NA Employee E8, and Licensed Practical Nurse (LPN) E9). Findings include: Review of facility policy Training Requirements dated 8/13/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum…

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 documents, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for four of seven staff members (Nurse Aide (NA) Employees E5, E6, and E8, and Licensed Practical Nurse (LPN) E9).Findings include: Review of facility policy Training Requirements dated 8/13/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Abuse, Neglect, and Exploitation…

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 documents, and staff interview, it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program for five of seven staff members (Registered Nurse (RN) Employee E3, Nurse Aide (NA) Employees E5, E6, and E8, and Licensed Practical Nurse (LPN) Employee E9).Findings include: Review of facility policy Training Requirements dated 8/13/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility…

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 documents, and staff interview, it was determined that the facility failed to provide training on Infection Control for four of seven staff members (Nurse Aide (NA) Employees E5, E6, and E8, and Licensed Practical Nurse (LPN) Employee E9).Findings include: Review of facility policy Training Requirements dated 8/13/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Infection Prevention, and Control…

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 documents, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for five of seven staff members (Registered Nurse (RN) Employee E3, Nurse Aide (NA) Employees E5, E6, and E8, and Licensed Practical Nurse (LPN) Employee E9).Findings include: Review of facility policy Training Requirements dated 8/13/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum…

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 records, and staff interview it was determined that the facility failed to ensure that three of five sampled Nurse Aides (NA) received a minimum of 12 hours of in-service education per year (NA Employees E5, E6, and E8).Findings include: Review of facility nurse aide training records revealed that NA Employee E5 did not receive 12 hours of in-service training in the last year. The facility was unable to provide documented evidence that NA Employee E5 had received a minimum of 12 hours of in-service training yearly. Review of facility nurse aide training records revealed that NA Employee E6 did not receive 12 hours of in-service training in the last year. The facility was unable to provide documented evidence that NA Employee E6 had received a minimum of 12 hours of in-service training yearly. Review of facility nurse aide training records revealed that NA Employee E8 did not receive 12 hours of in-service training in the last year. The facility was unable to provide documented evidence that NA Employee E8 had received a minimum of 12 hours of in-service…

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 documents, and staff interview, it was determined that the facility failed to provide training on Behavioral Health for five of seven staff members (Registered Nurse (RN) Employee E3, Nurse Aide (NA) Employees E5, E6, and E8, and Licensed Practical Nurse (LPN) Employee E9).Findings include: Review of facility policy Training Requirements dated 8/13/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum…

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 admission packet, facility policy, clinical records, observation, and staff interviews it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for two residents (Resident R3 and R44).Findings include: Review of the facility admission Packet policy dated 5/28/21, indicated the facility shall protect and promote the rights of each resident that include the right to a dignified existence, self-determination, communication with and access to, persons and services inside and outside the facility. Review of the facility Catheter Care policy dated 10/13/25 indicated that the facility will ensure that residents indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Review of the clinical record indicated Resident R3 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 review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide documentation that residents or resident representatives were given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of four residents reviewed (Resident R3, and R64).Findings include: A review of the facility Residents' Rights Regarding Treatment and Advance Directives policy dated 10/13/25, indicated that the facility will support and facilitate a resident's right to request, refuse or discontinue medical or surgical treatment and to formulate advance directives. On admission, the facility will determine if the resident has executed an advance directive and if not, determine whether the resident would like to formulate an advance directive. The facility will provide the resident or resident representative information on formulating advance…

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 interviews it was determined that the facility failed to develop a person-centered care plan with interventions for one of three residents reviewed (Resident R7).Findings include: Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 11/7/25, included diagnoses of suicidal ideation (when you think about, consider or feel preoccupied with the idea of death and suicide), schizophrenia (serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) and anxiety disorder (group of mental health conditions that cause fear, dread and other symptoms). Review of the plan of care for mood and behavior indicated the, a focus goal and intervention section: the focus was suicidal ideations with a goal section that failed to include a goal 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, facility documents and staff interviews, it was determined that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of four residents (Resident R8).Findings include: Review of facility policy Pressure Injury Prevention and Management dated 10/13/25, indicated the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injury. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review and staff interview it was determined that the facility failed to provide adequate supervision for one of three residents with mental health concerns to prevent attempts of suicide (Resident R7). Findings include: Review of facility policy Accidents and Supervision dated 10/13/25, indicated: The resident environment will remain free as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. Revie of facility policy Suicide ideation or attempt), dated 10/13/25, indicated: Plan of care for a resident after suicide ideation or attempt is to focus on immediate safety, comprehensive mental health evaluation, collaborative safety planning, and ongoing emotional support and monitoring. Immediate intervention: Ensure safety Do not leave the resident alone. One - on - One observation by a staff member until a professional evaluation is completed or risk is lowered. Remove any lethal means.…

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 policy, clinical record review and staff interview, it was determined that the facility failed to accurately assess the nutritional status and failed to update an individualized care plan to address the resident's specific nutritional concerns for one of three residents (Resident R8) records reviewed.Findings include: Review of facility's policy Nutritional Management, dated 10/13/25, indicated the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. A comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change in condition. The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's Minimum Data Set (MDS - a periodic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Resident R3 and R65). Findings include: Review of facility policy Oxygen Administration dated 10/13/25, indicated oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Change oxygen tubing weekly and as needed. Keep delivery devices covered in plastic bag when not in use. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/24/25, indicated diagnoses of depression, neurogenic bladder (nerve damage that interrupts bladder control), quadriplegia (a paralysis that affects all body limbs). Review of a physician's orders dated 12/1/25, indicated 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 facility policy, clinical documentation and staff interview it was determined that the facility failed to provide sufficient and timely social services to one of three residents reviewed (Resident R7).Findings include: Review of facility policy dated 10/13/25, Behavioral Health Services indicated:It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning.Review of facility policy dated 10/13/25, Suicide ideation or attempt indicated: Plan of care for a resident after suicide ideation or attempt is to focus on immediate safety, comprehensive mental health evaluation, collaborative safety planning and ongoing emotional support and monitoring. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 11/7/25, included diagnoses 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 facility policy, clinical record review, observation, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R36). Findings include: Review of facility Medication Administration policy dated 10/13/25, indicated medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. Ensure that the six rights of medication administration are followed: - Right resident- Right drug- Right dose- Right route- Right time- Right documentation Review of the clinical record indicated Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/2/25, indicated diagnoses of arthritis, depression, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of a physician order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility provided documents, clinical record review, and staff interviews it was determined that the facility failed to protect residents from neglect for one of three residents (Residents R1). This was identified for past non-compliance for Resident R1.Findings include: Review of the facility policy Abuse, Neglect and Exploitation last reviewed 10/13/25, indicated the facility is to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/11/25, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affect memory, thinking and interfere with daily life), and impulse disorder. 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 a review of facility policy, clinical record, and staff interview, it was determined that the facility failed to provide medications as ordered by the physician for two of four residents (Resident R1 and R2).Findings include: Review of Resident R1's admission record indicated the resident was admitted on [DATE], and readmitted on [DATE]. Review of Resident R1's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 9/24/25, indicated she had diagnoses that included high blood pressure, chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and retention of urine. Review of Resident R1's progress note dated 9/25/25, revealed the resident had a raised rash noted on the left side of trunk, under axillary area to hip. Right side of trunk, petechiae noted mid rib area. Review of Resident R1's follow up note entered by Certified Registered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident records, a facility tour, and staff and resident interview it was determined that the facility failed to implement transmission-based precautions and test for scabies for two of four residents (Residents R1 and R2).Findings include:The facility Head Lice and Scabies Exposure and Treatment policy dated 7/2/25 and last reviewed 10/13/25, indicated it is the policy of the facility to ensure residents who contract scabies are treated according to current standards of practice to eradicate the infestation and prevent further exposure and transmission. Human scabies is caused by the human itch mite. It is contagious and can be transmitted by direct prolong skin contact with an affected person. Proper treatment and infection control measures should be utilized to prevent outbreaks within the facility. The nurse will assess the resident who complaints of signs and symptoms of scabies (such as itching, scratching, papular rash, or burrows). The nurse will notify 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 record and staff interview it was determined that the facility failed to ensure that in preparation for a room change each resident/responsible party received written notice, including the reason for the change before the resident room was changed for one of three residents (Resident R1).Findings include: Review of facility policy Notification of Changes dated 7/1/25, indicated the purpose of this policy is to ensure the facility promptly informs the resident, physician, and notifies the resident's representative when there is a change requiring notification. Circumstances requiring notification include accidents, significant changes, the need to change treatment, a transfer or discharge, and a notice of room change. Review of Resident R1 was admitted to the facility on [DATE]. Review of Resident R1 clinical record MDS (minimum data set a periodic assessment of resident needs) dated 6/13/25, indicated diagnosis of anxiety (are a group of mental health conditions that cause fear, dread…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to make certain exit seeking/wandering residents had a person-centered care plan individualized to each specific resident's needs for one of six residents identified as high risk for wandering/elopement (Residents R1). Findings included: Review of the facility Care Plan Revisions Upon Status Change dated 7/1/25, indicated this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Review of the facility Elopements and Wandering Residents dated 7/1/25, indicated the facility ensures that residents who exhibit wandering behavior and are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered care addressing the unique factors contributing to wandering or elopement risk. The facility shall implement interventions to reduce risks and modify…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to provide adequate supervision to prevent elopement for one of six residents (Resident R1).Findings include: Review of the facility Elopements and Wandering Residents dated 7/1/25, indicated the facility ensures that residents who exhibit wandering behavior and are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered care addressing the unique factors contributing to wandering or elopement risk. The facility shall implement interventions to reduce risks and modify interventions when necessary. Review of Resident R1 was admitted to the facility on [DATE]. Review of Resident R1 clinical record MDS (minimum data set a periodic assessment of resident needs) dated 6/13/25, indicated diagnosis of anxiety (are a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to 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 facility policy, national accepted guidelines for Pressure Ulcers, and staff interview, it was determined that the facility failed to accurately assess pressure ulcers for one of three residents (Resident R2). Findings include: The facility policy Wound Treatment Management reviewed 12/3/24 indicated to promote wound healing of various wounds, it is the policy of the facility to provide evidence-based treatments in accordance with current standards or practice and physician orders. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 5/22/25, indicated that Resident R2 had diagnoses that included thrombophilia(a condition where the blood has an increased tendency to clot), chronic embolism and rhabdomyolysis(condition where damaged muscle tissue breaks down, releasing its…

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, staff, and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance, including eating and toileting for four of seven residents (Resident R4, R5, R6, and R7). Findings include: Review of the facility's Activities of Daily Living (ADLs) policy dated 11/27/24, indicated care and services such as eating, transferring, and toileting will be provided. A resident who is unable to carry out activities of daily living will receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility's undated Certified Nursing Assistant job description revealed major duties and responsibilities include performing activities of daily living (ADL) for residents in accordance with care plans and established policies and procedures, assist nursing staff in carrying out toileting program activities, and complete flow sheets daily to indicate the specified task was done. Additional tasks…

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, facility policy, job descriptions, and resident and staff interviews, it was determined that the facility failed to have sufficient staff to provide nursing services including toileting for three of seven residents reviewed (Residents R5, R6, and R7). Findings include: Review of the facility's Activities of Daily Living (ADLs) policy dated 11/27/24, indicated care and services such as transferring and toileting will be provided. A resident who is unable to carry out activities of daily living will receive necessary services to maintain good grooming and personal hygiene. Review of the facility's undated Certified Nursing Assistant job description revealed major duties and responsibilities include performing activities of daily living (ADL) for residents in accordance with care plans and established policies and procedures, assist nursing staff in carrying out toileting program activities, and complete flow sheets daily to indicate the specified task was done. Additional tasks…

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, facility policy, and staff interview, it was determined that the facility failed to ensure comfortable air temperature levels were provided for eight of 49 resident rooms (209, 212, 218, 219, 221, 302, 303, and 305). Findings Include: Review of the facility policy Safe and Homelike Environment indicated the facility will provide a safe, clean, comfortable, and homelike environment. The facility will provide and maintain comfortable and safe temperature levels. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. Observations conducted on 6/10/25, from 2:32 p.m. to 2:59 p.m. with the Maintenance Director, Employee E7 revealed the following air temperatures: 2nd floor Nursing Floor -room [ROOM NUMBER]-82.2 of degrees Fahrenheit -room [ROOM NUMBER]-81.5 of degrees Fahrenheit -room [ROOM NUMBER]-82.4 of degrees Fahrenheit -room [ROOM NUMBER]-82.8 of degrees Fahrenheit -room [ROOM NUMBER]-82.8 of degrees Fahrenheit 3nd floor 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and documentation, staff and resident interview it was determined that the facility failed to protect resident from neglect for two of four residents (Resident R4 and Resident R5). Findings include: Review of facility's policy dated 11/27/24, Abuse, Neglect, and Exploitation stated it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse and neglect. Neglect means failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident R4's admission record indicated resident was admitted to facility on 1/27/25, with the diagnosis of chronic pain, hemiplegia (paralysis of one side of the body), and weakness. Review of Residents R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/27/25,…

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, facility documents, and staff interviews, it was determined that the facility failed to schedule an appointment for outside services in a timely manner for one of three residents (Resident R5). Findings include: Review of the clinical record revealed that Resident R5 was admitted to the facility on [DATE], with diagnoses of depression, anxiety, diabetes (occurs when your blood sugar is too high). Review of Resident R5's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/2/25, indicated diagnoses were current. Review of Resident R5's physician order dated 5/23/25, indicated to consult dermatology for ongoing rash. Review of Resident R5's clinical record revealed on 5/27/25, Medical Doctor, Employee E4 seen the resident for a monthly follow up. The resident was complaining of their chronic rash, that is getting worse. The resident's skin was observed to have a rash present, hands are scaly, very dry. It was indicated a skin scraping was completed of the…

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

Based on review of facility policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of three of ten residents (Residents R1, R2, and R3). Findings Include: Review of the facility policy, Resident Showers dated 12/3/24, indicated residents will be provided showers as per request or as per facility schedule protocols and based on resident safety. During an interview on 3/4/25, at 10:13 a.m. Resident R1 stated I didn't get a shower on Monday because they were low on staff. I am scheduled for showers on Mondays and Thursdays. Now I have to wait until Thursday. This isn't the first time this has happened. It happens a lot. Review of Resident R1's clinical record revealed a nurses note dated 2/27/25, that stated the following Shower twice weekly on Monday and Thursday's daylight shift in the morning every Monday, Thursday. Client requesting to be a daylight shower Unable 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 a review of facility documents, observations, and staff interviews, it was determined that the facility failed to maintain a homelike environment on one of two nursing floors (Second floor). Findings include: A review of facility policy Safe and Homelike Environment dated 12/3/24, indicated that residents are provided with a safe, clean, comfortable, and homelike environment. During an observation on 3/5/25, from 10::10 a.m. through 10:20 a.m. the following was revealed: -Second Floor C4 shower room, brown/rust colored ceiling tiles were noted -Second Floor C3 bathroom an area of approximately 15 inches wide and four inches high of cracked and peeling plaster was noted on the wall. -Second Floor Restroom across from nurses' station (far left) had brown stained ceiling tiles, and an area of approximately 24 inches across of chipped paint and plaster. -Second Floor Restroom across from the nurses' station (middle) had an area of approximately 24 inches across of chipped paint and plaster. -Second Floor Restroom across form the nurses' station (far right) had an area 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 facility policy, job description, clinical record review, facility documents, resident interview, and staff interviews it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of two residents reviewed (Resident R1). Findings include: Review of the facility's Registered Nurse (RN) job description indicated the RN will prepare and administer medications as ordered by the physician. Review of facility policy Medication Administration dated 12/3/24, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Compare medication source (such as, bubble pack and vials). Ensure that the six rights of medication administration are followed: - Right resident - Right drug - Right dose - Right route - Right time - Right documentation Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, facility documents, resident interview, and staff interviews it was determined the facility failed to ensure that residents were free from any significant medication errors for one of two residents. (Resident R1). Findings include: Review of facility policy Medication Administration dated 12/3/24, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Compare medication source (such as, bubble pack and vials). Ensure that the six rights of medication administration are followed: - Right resident - Right drug - Right dose - Right route - Right time - Right documentation Review of the admission record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included influenza (flu- a viral infection of the nose, throat, and…

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

Based on review of facility policy, facility grievance forms, group interview, resident interview, and staff interview it was determined that the facility failed to respond to concerns from facility grievances and failed to respond to concerns in a timely manner for six out of six months (June 2024 through November 2024). Findings include: The facility policy Resident and Family Grievances dated 12/3/24, indicated that the facility will support each residents and family members right to voice grievances without discrimination, reprisal, or fear of discrimination. The grievance official is responsible for overseeing the grievance process. The written decision will include at a minimum: - The date the grievance was received. - The steps taken to investigate the grievance. - A summary of the pertinent findings or conclusions regarding the resident ' s concern. - A statement as to whether the grievance was confirmed or not confirmed. - Any corrective action taken. - The date the written decision was issued. Review of facility provided grievance forms on 12/17/24, at 10:53 a.m. revealed…

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

Based on observations and staff interview it was determined that the facility failed to have required postings for the facility in areas that are accessible to all residents throughout the facility for State Agency information, Adult Protective Service information, Medicare Fraud Unit information, and how to file a complaint with State Agency on two of two nursing floors (Second and Third Floor). Findings include: Observation by the facilities entrance bulletin board had required postings displayed, however residents would be required to descend a staircase consisting of nine steps to view the postings and climb back up nine step to get back to the Main Floor. Observation on the nursing care units on the second and third floor failed to include information on State Agency, Adult Protective Services, Medicare Fraud Unit, and how to file a complaint with State Agency. During an interview on 12/19/24, at 1:39 p.m. Nursing Home Administrator confirmed that the facility failed to post above required information where it is easily accessible to residents to refer to, if needed, for two of…

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

Based on observations and staff interview, it was determined the facility failed to display written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid on two of two nursing units (Second, and Third Floor). Findings include: Observation by the facilities entrance bulletin board had required postings posted, however residents would be required to descend a staircase consisting of nine steps to view the postings and climb back up nine step to get back to the Main Floor. Observation on the nursing care units on the second and third floor failed to include information on how to apply for Medicare and Medicaid. During an interview on 12/19/24, at 1:39 p.m. Nursing Home Administrator confirmed that the facility failed to post above required information where it is easily accessible to residents to refer to, if needed, on two of two nursing units (Second and Third Floor). 28 Pa. Code: §201.29(i) Resident rights.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of three resident hospital transfers (Residents R17, R18, and R47). Findings include: Review of facility policy Transfer and Discharge (Including AMA) dated 12/3/24, indicated during an emergency transfer/discharge, the facility will provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated. Review of the clinical record indicated that Resident R17 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/1/24, indicated diagnoses of Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs), Obstructive Sleep Apnea (a sleep disorder in which the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for three of twelve residents (Residents R1, R17, and R91). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of resident care needs), dated October 2024, indicated the following: Section A1500: Preadmission Screening and Resident Review (PASRR): code 1, yes if: PASSR Level II screening determined that the resident has a serious mental illness and/or ID/DD (Intellectual Disability/Developmental Disability) or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. Section A2105: Discharge Status: This item documents the location to which the resident is being discharged at the time of discharge. Select the two-digit code that corresponds…

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

Based on a review of the clinical record, resident council group, and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for four of four weeks (December 2024). Findings include: Review of facility policy Activities dated 12/3/24, indicated the facility is to provide an ongoing program to support residents in their choice of activities. Facility group, individual, and independent activities will be designed to meet the interest of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will include individual, small, and large group activities. Activities will be designed with the intent to; - Enhance the resident's sense of well-being, belonging, and usefulness. - Create opportunities of each resident to have a meaningful life. - Promote or enhance physical activity. - Promote or enhance cognition. - Promote or enhance emotional health. - Promote self-esteem, dignity, pleasure,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for five of 20 residents (Residents R17, R45, R47, R50, and R53). Findings include: Review of facility policy Hypoglycemia Management dated 12/3/24, indicated if the blood glucose reading is 70 mg/dL (milligram per deciliter) or below, the nurse will utilize the hypoglycemic protocol as per the practitioner's orders, with follow up blood glucoses as indicated, and notify the practitioner of the results as ordered. The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies and biologicals in one of three medication carts (3A medication cart), and in one of three medication rooms (Medication room [ROOM NUMBER]BC) and failed to properly secure a medication cart for one of three medication carts (3A medication cart). Findings include: Review of facility Medication Storage policy dated 12/3/24, indicated the facility will ensure all medication housed on our premises will be stored in the medication rooms according to manufacturer's guideline. All drugs and biologicals will be stored in locked compartments. During a medication pass, medication must be under the direct observation of the person administering medications or locked in the medication storage area or cart. During a tour of the facility on 12/17/24, at 10:53 a.m. revealed a medication cart that was unattended, and unlocked on 3A. During an interview on 12/17/24, at 11:00 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for three of six residents (Resident R17, R34, and R66). Findings include: A review of the facility policy Documentation in Medical Record dated 12/3/24, and previously dated 9/12/24, indicated that each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Review of the clinical record indicated that Resident R17 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs), Obstructive Sleep Apnea (a sleep disorder in which the throat muscles relax and block the airway, causing breathing to become restricted and briefly…

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

Based on review of facility policy, clinical records, group interview, and staff interviews, it was determined that the facility failed to inform residents in advance of the proposed care for two of seven residents (Resident R39 and Resident R66). Findings include: The facility policy Resident rights reviewed 12/3/24, indicated that the facility will support and facilitate a resident's right to request, refuse, and discontinue medical or surgical treatment. The facility will provide the resident information in a manner that is easy to understand. During a group interview on 12/17/24, at 1:30 p.m. two of seven residents voiced concerns of not knowing in advance of when their appointments are. During a group interview residents stated they used to get index cards prior to their appointment with who their appointment was for, date, and what time their appointment was for. During a group interview residents voiced concern about not having enough time to prepare for an appointment and stated I'd like to know at least a day ahead so I know that I need to get ready instead of the same day,…

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, staff and resident interview, it was determined that the facility failed to accommodate resident needs and preferences for one of six residents (Resident 71). Findings include: Review of Resident R71's clinical record indicated he was admitted to the facility on [DATE], with diagnoses of depression, insomnia (difficulty falling or staying asleep), and orthostatic hypotension (a drop in blood pressure when you stand up, which can cause dizziness, fainting, and other symptoms). Review of Resident R71's MDS dated [DATE], indicated the diagnoses were current. Review of Resident R71's progress note dated 9/26/24, entered by Social Service Director, Employee E4 stated she attempted to order a free phone for the resident however was unable to complete the process as it required a debit card for a processing fee. During an interview on 12/16/24, at 10:43 a.m. Resident R71 stated he asked the social worker to help him apply for a free phone. He stated it's been a while. Review of 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 facility policy, clinical records, and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of two residents (Resident R47, and R142). Findings include: A review of the facility Resident Rights Regarding Treatment and Advance Directives dated 12/3/24, and previously dated 9/12/24, indicated that upon admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. Review of Resident R47's admission record indicated the resident was admitted to the facility 3/10/23. A review of Resident R47's Minimum Data Set (MDS - periodic assessment of care needs) dated 11/8/24, included diagnoses of depression, diabetes (a metabolic disorder in which the body has high sugar levels 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to notify the family and/or physician of a change in condition in a timely manner for two of six residents (Resident R17 and R39). Findings include: Review of the facility policy Notification of Changes dated 12/3/24, indicated purpose of this policy is to ensure the facility promptly inform the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification such as a significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health. This may include life threatening conditions, clinical complications, or a transfer of the resident from the facility.…

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

Based on a review of facility documents and staff interview, it was determined that the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) form notice were provided timely for one of three residents (Resident R76). Findings include: Review of facility policy Advance Beneficiary Notices dated 12/3/24, indicated it is the policy of the facility to provide timely notices regarding Medicare eligibility and coverage. To ensure that the resident or representative had enough time to make a decision whether or not to receive the services and assume financial responsibility the notice shall be provided at least two days before the end of coverage. Review of Resident R76's admission record indicated the resident was admitted to the facility 10/23/24. Review of Resident R76's Minimum Data Set (MDS - periodic assessment of care needs) dated 10/30/24, included diagnoses of thyroid disorder (any dysfunction of the butterfly-shaped gland at the base of the neck), depression, and shortness of breath. Review of the NOMNC form indicated services will end 10/31/24. Resident R76 signed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of three medication carts (2A Medication Cart). Findings include: Review of facility policy Confidentiality of Personal and Medical Records dated 12/3/24, indicated this facility honors the resident's right to secure and confident personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record. During an observation on 12/16/24, at 10:42 a.m. the 2A Medication Cart outside of resident room [ROOM NUMBER] was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. During an interview on 12/16/24, at 10:43 a.m. Registered Nurse Employee E1 confirmed the above observation and that the facility failed to maintain 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 facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of neglect for one of three residents (Resident R6) and failed to conduct a criminal background check prior to the start of employment for one of five staff (Dietary Employee E21). Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 12/3/24, indicated neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Possible indicators of abuse include failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning and repositioning. An immediate investigation is warranted when suspicion or abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to report an allegation of neglect in the required timeframe one of three residents (Resident R6). Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 12/3/24, indicated neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Possible indicators of abuse include failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning and repositioning. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of the clinical…

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 documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of an allegation of neglect for one of three residents (Resident R6). Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 12/3/24, indicated neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Possible indicators of abuse include failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning and repositioning. An immediate investigation is warranted when suspicion or abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) 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 a review of facility documents, and resident and staff interview, it was determined that the facility failed to not distinguish between residents based on their source of payment when providing services that are required to be provided for two of twelve residents (Resident R45, and R87). Findings Include: Review of the clinical record indicated Resident R45 was admitted to the facility on [DATE]. Review of Resident R45's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/26/24, indicated diagnoses of high blood pressure, muscle weakness, and adult failure to thrive (seen in older adults with multiple medical conditions resulting in downward spiral of poor nutrition, weight loss, inactivity, depression, and decrease in functional abilities). Review of a physician order dated 11/26/24, indicated dental consult ASAP (as soon as possible), for abscess (a swollen area within body tissue, containing an accumulation of pus)/infection. Review of Resident R45's care plan dated 11/27/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of two residents with facility-initiated transfers (Residents R18 and R47). Findings include: Review of facility policy Transfer and Discharge (Including AMA) dated 12/3/24, indicated for a transfer to another provider, for any reason, the following information must be provided to the receiving provider: contact information of the practitioner who was responsible for the care of the resident, resident representative information including contact information, advice director information, all other information necessary to meet the resident's needs, which includes but is not limited to resident status, diagnoses and allergies, medications, most recent relevant labs, diagnostic tests, treatments, special risks, and the resident's comprehensive care plan. Review of the clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, resident, and staff interviews, it was determined that the facility failed to complete quarterly wander guard (a device that triggers alarms when close to an exit) assessments for two of two residents (Resident R8, and Resident R53). Findings include: Review of facility Elopements and Wandering Residents policy dated 12/3/24, indicated that the facility ensures that residents who exhibit wandering behavior and at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay. Review of Resident R8's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R8's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 10/2/24, indicated diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents were provided appropriate treatment and services to maintain bowel function for one two residents (Resident R36). Findings include: Review of facility policy Medication Administration dated 12/3/24, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review MAR (Medication Administration Record) to identify medication to be administered. Review of the clinical record indicated Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/1/24, indicated diagnoses of high blood pressure, muscle wasting, and Post Traumatic Stress Disorder (PTSD - a disorder in which a person…

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 facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for one of two residents reviewed (Resident R39). Findings include: Review of facility policy Ostomy Care-Colostomy, Urostomy, and Ileostomy dated 12/3/24, indicated it is the facility policy to ensure that residents who require colostomy (a stoma that has been constructed by connecting a part of the colon onto the anterior abdominal wall) services receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Ostomy care will be provided by licensed nurses under the orders of the attending physician. Review of the clinical record indicated that Resident R39 was admitted to the facility on [DATE], with diagnoses of overactive bladder and kidney disease. Review of the Minimum Data Set (MDS - a periodic…

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, clinical record review, and staff, resident, and family interviews, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Residents R17). Findings include: Review of the facility policy Noninvasive Ventilation dated 12/3/24, indicated it is the policy of the facility to provide non-invasive ventilation as per physician orders and current standards of practice. The facility will obtain an order for the use of a BIPAP (a mechanical breathing device that uses positive pressure ventilation to treat sleep apnea and other health conditions that affect your breathing) device and settings from the practitioner. If a resident's personal BIPAP device is brought into the facility, the nurse/respiratory therapist will verify settings on the machine prior to use. The facility will follow manufacturer instructions for the frequency of cleaning/replacing filters and servicing the machine. Only the supplier may service…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for one of one dialysis resident (Resident R64). Findings include: Review of the admission record indicated Resident R64 was admitted to the facility on [DATE]. Review of Resident R64's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/29/24, indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), renal failure (condition where the kidneys lose the ability to remove waste and balance fluids) with dialysis, and high blood pressure. Review of current physician orders on 1/30/24, indicated Resident R64 attends dialysis on Monday, Wednesday, and Friday each week. A review of the clinical record did not include complete communication forms for the month of December 2024. There were seven incomplete communication sheets (Portion Completed by Nursing Home was incomplete) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents (Resident R36 and R85). Findings include: Review of facility policy Trauma Informed Care dated 12/3/24, indicated the facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health professionals to develop and implement individualized care plan interventions. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which may re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the residents care plan. Review 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 observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for one of two residents (Resident R56). Findings include: Review of facility policy Proper Use of Bed Rails dated 12/3/24, indicated a nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, or a change in the type of bed/mattress/rail. Review of the clinical record indicated Resident R56 was admitted to the facility on [DATE]. Review of Resident R56's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/2/24, indicated diagnoses of high blood pressure, muscle weakness, and anemia (too little iron in the blood). Review of a physician order dated 7/26/22, indicated bilateral (both sides) bed…

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, hospital records review, facility policy review, and staff interview, it was determined that the facility failed to ensure that the resident's total program of care, including medications and treatments, were reviewed with accuracy at each physician visit for one of three residents reviewed (Resident 1). Findings include: Review of the facility policy Provision of Physician Ordered Services dated 12/3/24, indicated the purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of practice. Review of the clinical record indicated that Resident R17 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs), Obstructive Sleep Apnea (a sleep disorder in which the throat muscles relax and block the airway, causing breathing to become restricted and briefly stop), and respiratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for one of three nurse aide personnel records (Nurse Aide Employee E26). Findings include: The facility Certified Nursing Assistant position description last reviewed 12/3/24, indicated that compliance is a factor in evaluating job performance. It was indicated individual performance will be evaluated using a scale ranging from unsatisfactory to exceeds standards. Review of Nurse aide (NA) Employee E26's personnel record indicated she was hired to the facility on [DATE]. The record indicated that the position description and the employee handbook were both signed on 11/30/23. Review of Nurse aide (NA) Employee E26's performance evaluation on 12/20/24, at 9:30 a.m. for the evaluation period of 11/30/23 to 1/30/24, failed to reveal an annual performance evaluation was performed. During an interview on 12/20/24, at 9:38 p.m. the Director of Human Resources…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical documentation. observation and staff interview it was determined the facility failed to dispose and reconcile discontinued medication in a timely manner for one of two residents (Resident R55). Findings: Review of facility policy Discontinued Medications, dated 12/3/24, indicated when medications are discontinued by prescriber order, a resident is transferred or discharged and does not take medications with him or her, or in the event of resident ' s death, the medications are marked as discontinued and destroyed or returned to the issuing pharmacy. Medications are stored in a locked secure area designated for that purpose until destroyed. Review of the clinical record indicated Resident R55 was admitted to the facility on [DATE]. Review of Resident R55's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/16/24, indicated diagnoses of depression, muscle weakness, and hypothyroidism (a condition in which they thyroid gland doesn't produce…

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 review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRR) were completed by the facility after the consultant pharmacist recommendations were made for two of two residents (Resident R48, and Resident R53). Findings include: The facility policy Medication Regimen Review and Reporting reviewed 12/3/24, indicated a MRR is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. Review of Resident R48's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R48's MDS assessment (Minimum Data Set assessment: MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to ensure that a resident's physician was promptly notified about abnormal laboratory test results for one of two residents (Resident R34) Findings include: The facility policy Notification of Changes: dated 12/3/24, and previously dated 9/12/24, indicated that the facility will promptly inform the physician when there is a change requiring notification. Review of the clinical record revealed that Resident R34 was admitted to the facility on [DATE] from a hospital. Review of Resident 34's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (a disorder in which the body has high sugar levels for prolonged periods of time), and pain. Review of medical records revealed that Resident R34 had a physician's order dated 9/20/24, indicated to complete a CBC (Complete Blood Count- a group of blood tests that measure the number and size of the different cells in your body), 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 facility policies, clinical record review, and staff interviews, it was determined that the facility failed to provide timely dental services for one of two residents reviewed (Resident R45). Findings include: Review of facility policy Dental Services dated 12/3/24, indicated the facility is to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Emergency dental services includes services needed to treat and episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. Review of the clinical record indicated Resident R45 was admitted to the facility on [DATE]. Review of Resident R45's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/26/24, indicated diagnoses of high blood pressure, muscle weakness, and adult failure to thrive (seen in older adults with multiple medical conditions resulting in downward…

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 documents, and resident and staff interview, it was determined that the facility failed to provide specialized rehabilitative services for one of six residents (Resident R87). Findings Include: Review of the clinical record revealed that Resident R87 was admitted to the facility on [DATE]. Review of Resident 87's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 12/3/24, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes (a disorder in which the body has high sugar levels for prolonged periods of time). Review of medical records revealed that Resident R87 had physician's orders for Physical Therapy (PT) Evaluation and Treatment as needed, and Occupational Therapy (OT) Evaluation and Treatment as needed, and a Speech Therapy (ST) Evaluation and Treatment as needed, all dated 11/26/24. Review of medical record revealed a Rehabilitation admission Screen 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 a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a diagnosis, and order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for one of two residents (Resident R12). Findings include: Review of the facility policy Providing End of Life Care dated 12/3/24, and previously dated 9/12/24, indicated that if a resident chooses hospice services (care for terminally ill residents) the plan of care will include the resident's underlying diagnoses. The facility will maintain communication with Hospice. Review of the clinical record revealed that Resident R12 was admitted to the facility on [DATE]. Review of Resident 12's MDS (Minimum Data Set- periodic assessment of resident care needs) dated 11/15/24, indicated diagnoses of high blood pressure, diabetes (a disorder in which the body has high sugar levels for prolonged periods of time), 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 facility policy, observations, and staff interviews, it was determined that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R84) Findings include: A review of the facility policy Enhanced Barrier Precautions, last reviewed 12/3/24, indicated enhanced barrier precautions will be implemented for residents who have a wound. Review of the Center for Disease Control How to Safely Remove Personal Protective Equipment (PPE) indicated all PPE is removed before exiting the patient room except a respirator, if worn. The first step of doffing PPE is removing the gown. Then the gloves are removed without contaminating your hands. A review of the facility procedure Hand Hygiene last reviewed 12/3/24, indicated staff must perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Handwashing should take about 20 seconds and a clean towel is used to turn…

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 a clean homelike environment in one of two nursing units (Second Floor). Findings include: Review of facility policy Safe and Homelike Environment dated 9/12/24, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment. During an observation on 11/19/24, at 10:50 a.m. the Resident's Day Room (activity/dining area) in the 200 hallway indicated two wheelchairs and a stretcher were being stored in the room. During an interview on 11/19/24, at 11:08 a.m. Registered Nurse (RN) Employee E1 confirmed the above observation. RN Employee E1 stated, Resident wheelchairs are stored in the hallway during the morning while staff are getting residents out of bed. In the evenings, equipment is stored in the Day Rooms. The stretcher was left by transport. During an interview on 11/19/24, at 1:39 p.m. the Director of Nursing confirmed that the facility failed to maintain a clean homelike environment in one of two nursing units as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for one of five residents (Resident R1). Findings include: Review of facility policy Care Plan Revision Upon Status Change dated 9/12/24, indicated the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses of depression (a constant feeling of sadness and loss of interest), anxiety (a feeling of worry, nervousness, or unease), and constipation (a problem with passing stool). Review of a Nursing Progress Note dated 11/6/24, at 10:45 a.m. completed by the Director of Nursing (DON) stated, Resident demanding to be sent to ER (emergency room) stating that he needed to have a bowel movement. He had however moved…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to properly secure a medication cart while not in use for one of four medication carts (Medication Cart 3C). Findings include: Review of facility policy Medication Storage dated 9/12/24, indicated all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. During an observation on 11/19/24, at 11:24 a.m. the 3C Medication Cart was observed outside of resident room [ROOM NUMBER] with the cart unlocked and unattended. During an interview on 11/19/24, at 11:25 a.m. Licensed Practical Nurse Employee E2 confirmed the 3C Medication Cart was unlocked and unattended. During an interview on 11/19/24, at 1:39 p.m. the Director of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to follow physician orders for surgical wound care for one out of three residents (Resident R1). Findings include: Review of facility policy Wound Treatment Management, dated 9/12/24, revealed that wound treatments will be provided in accordance with physician order. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. Review of hospital documentation revealed that Resident R1 was discharged from the hospital on 9/9/24, after receiving surgery to the spine. Review of hospital discharge documents included a physician's orders to provide wound care to Resident R1's surgical incision on her back with a dry dressing, daily. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 9/16/24, indicated diagnoses of high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of four of eight residents (Residents R1, R2, R3, R4). Findings Include: Review of the facility policy Accidents and Supervision dated 5/24/23, last reviewed 9/12/24, indicated each resident will receive adequate supervision and assistive devices to prevent accidents. Review of the facility policy Nursing Services and Sufficient Staff dated 5/24/23, last reviewed 9/12/24, indicated it is the facility policy to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Review of the facility policy Fall Prevention Program dated 5/24/23, last reviewed…

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 personnel files, as well as staff interviews, it was determined that the facility failed to ensure that the status of nursing licenses were checked with the State Board of Nursing and failed to ensure that references were checked from previous employers and/or current employers for one of one newly hired nurses reviewed (Registered Nurse 1). This deficiency was cited as past non-compliance.Findings include:The facility's policy regarding abuse, neglect, and exploitation, dated July 6, 2022, indicated that potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. The facility will maintain documentation of proof that the screening occurred.The personnel file for Registered Nurse 1 revealed a start date of November 30, 2022. However, there was no documented evidence that her license was checked…

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 facility policy and clinical record review, and staff interview, it was determined the facility failed to notify a resident of a room change and the physician for a change in condition for three of five residents (Resident R12, R34, and R85). Findings include: Review of the facility policy Notification of Changes last reviewed 2/21/23, indicated the facility will promptly inform the resident, consult the resident's physician, and notify the resident's representative when there is a change requiring notification. It was indicated if a change in the resident's room occurs, the facility must inform the resident. Review of the facility policy Change of Room or Roommate dated 2/21/23, stated it is the policy of the facility to notify a resident in writing prior to changing a resident's room, and it must include the reason for the room change. Review of the face sheet indicated Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS- a periodic assessment of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical record, incident reports, facility supplied documentation, and staff interview it was determined that the facility failed to report allegations of abuse for four of six residents (Resident R12, R43, R84, and R85). Findings include: The facility policy Abuse, Neglect, and Exploitation dated 2/21/23, indicated the facility staff must immediately, no later than 24 hours after the allegation is made, report all alleged allegations of abuse to the Administrator, State agency, adult protective services, and to all other required agencies. Review of the face sheet indicated Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/11/23, indicated the diagnoses of high blood pressure, diabetes (too much sugar in the blood), and depression. A review of Resident R12's progress note dated 12/25/23, stated resident states she won't take care of me and she threw my EpiPen at me 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 facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate allegations of abuse for four of six residents reviewed (Resident R12, R43, R84, and R85). Findings include: The facility policy Abuse, Neglect, and Exploitation dated 2/21/23, indicated it is the facility's policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. Neglect, exploitation, and misappropriation of resident property. The Administrator must follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation within final within five working days of the incident, as required by stated agencies. Review of the face sheet indicated Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS- a periodic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to implement the bowel regimen protocol and provide treatment as required for four of six residents (Resident R1, R34, R63, and R237). Findings include: Review of facility policy Provision of Quality Care dated 2/21/23, indicated the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice. A review of the Bowel Routine Policy dated 2/21/23, indicated if a resident has not had a bowel movement in three days (six shifts), 30 ml of Milk of Magnesia (a stimulant laxative used to treat constipation) must be administered. If Milk of Magnesia is ineffective, then a Dulcolax Suppository (a laxative that stimulates bowel movement designed to be inserted into the rectum to dissolve) must be administered on Day 4. If still no bowel movement then a fleet enema (liquid medicine used to help you have a bowel movement that is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observation and staff interviews it was determined that the facility failed to maintain resident dignity by not clothing a resident on the Third floor (Resident R74) and failing to cover a resident's catheter bag (Resident R14) for two of five residents. Findings include: The facility Promoting and maintaining dignity policy last reviewed 2/21/23, indicated that it is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity. Review of the facility Catheter Care policy last reviewed 2/21/23, indicated the catheter bag should have a privacy cover applied at all times. During an observation on 1/4/24, at 9:25 a.m. Resident R14 was observed utilizing a foley catheter without a privacy cover on the urine collection bag. During an observation on 1/4/24, at 9:30 a.m. Licensed Practical Nurse, Employee E6 confirmed Resident R14 did not have a dignity bag covering the urine collection bag and confirmed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, notice of non-coverage documents, clinical record review and staff interview, it was determined that the facility failed to provide the Advanced Beneficiary Notice prior to discharge from Medicare Part A services for one of three sampled residents (Resident R83). Findings include: The facility Statement of resident rights policy indicated that the resident has the right to receive information about the services available in the facility and about the charges for those services, including any changes for services not covered under Medicare. Review of Resident R83's admission record indicated he was admitted on [DATE], with diagnoses that included hypertension (a condition impacting blood circulation through the heart related to poor pressure), diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), and anxiety disorder. Review of Resident R83's MDS assessment (Minimum Data Set Assessment-MDS: a periodic assessment of resident 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.

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 clean homelike environment in one of two nursing units (second floor), and two of two facility elevators (Elevator A and Elevator C). Findings Include: Review of the facility policy Safe and Homelike Environment dated 2/21/23, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment. Observation on 1/2/23, at 9:20 a.m. Resident R21's resident room [ROOM NUMBER]A, indicated a ceiling tile above the head of the bed area that was stained brown. Observation on 1/2/23, at 9:42 a.m. Resident R187's resident room [ROOM NUMBER], indicated peeling plaster down the wall by the window, with lifted and jagged edges protruding from wall. Observation on 1/2/23, at 9:53 a.m. Residents' Day Room (activity/dining area) in the 200 hallway indicated 15 wheelchairs were stored to the right side of the room, occupying over a quarter of the room's space. Observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations of resident areas and nursing units, and staff interview it was determined that the facility failed failed to post all required information to submit a grievance on two of three resident areas (Second floor and Third floor). Findings include: The facility Resident and family grievances policy dated 2/21/23, indicated that it is the poicy of the facility to support each resident's right to voice grievances. During a tour on 1/2/24, the following was observed: At 11:41 a.m. observations of the postings on the Third floor common areas and hallways found no grievance procedure or grievance policy posted. At 11:52 a.m. observations of the postings on the Second floor common areas and hallways found no grievance procedure or grievance policy posted. During a tour on 1/3/24 with the Director of Social Services Employee E1, the following was observed: At 9:38 a.m. the Second Floor day room by room [ROOM NUMBER] was observed with no grievance policy posted (name 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 facility policies, documents and clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from abuse and neglect for one of six residents reviewed (Resident R31). Findings include: The facility's policy Abuse Neglect, and Exploitation Policy dated 2/21/23, indicated it is the facility's policy to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse neglect, exploitation and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of admission record indicated Resident R31 was admitted to the facility on [DATE]. Review of Resident R31's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/4/23, indicated 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 the Minimum Data Set (MDS-periodic assessment of resident care needs) User's Manual, clinical record, and staff interview, it was determined that the facility failed to complete a comprehensive assessment after a significant change in condition for one of four residents receiving hospice services (Resident R21). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a significant change in status assessment is required to be performed when a terminally ill resident enrolls in a hospice program and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14-days from effective date of the hospice election. Review of the admission record indicated Resident R21 was admitted to the facility on [DATE]. Review of Resident R21'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Minimum Data Set (MDS-a periodic assessment of resident care needs) user's manual, facility policy, clinical records and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of two sampled residents (Resident R74). Findings include: The Resident Assessment Instrument (RAI) User's Manual (the manual providing instructions for completing Minimum Data Set assessments) dated 10/2023 indicated that the intent of the active diagnoses section is to code diseases that have a direct relationship to the resident ' s current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident ' s current health status. The facility Conducting an accurate resident assessment policy last reviewed 2/21/23, indicated that accuracy of assessment means that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident observations, clinical record review and staff interviews, it was determined that the facility failed to develop a plan of care to include a focus and interventions to maintain a resident's highest practicable physical well-being as required for three of six residents (Resident R14, R44, and R63). Findings include: Review of the facility Care Plan policy dated 2/21/23, indicated the facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Review of the facility Catheter Care policy last reviewed 2/21/23, indicated it is the facility's policy to ensure residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Review of the facility Hemodialysis policy dated 2/21/23, indicated…

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 facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for one of two residents reviewed (Resident R40). Findings include: Review of facility policy Ostomy Care- Colostomy, Urostomy, and Ileostomy dated 2/21/23, indicated the frequency of pouch changes and the products required for changing ostomy devices will be noted on the resident's plan of care for the ostomy. It was indicated the comprehensive care plan will reflect any special products or pouching techniques needed to prevent or manage any skin breakdown surrounding the ostomy. Interventions to prevent complications or promote dignity associated with the ostomy will be included in the person-centered care plan. Review of the admission record indicated Resident R40 was admitted to the facility on [DATE], and readmitted [DATE] Review of Resident R40's MDS dated [DATE], indicated the diagnoses…

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

Based on review of facility policies, observations and staff interview it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two nursing units (second floor). Findings include: Review of the facility policy Storage of Medications dated 2/21/23, indicated medications are stored in locked compartments, only authorized personnel will have access to keys to locked compartments, and during a medication pass all medications must be in direct observation of the person administering the medications. Observation on 1/2/24, at 10:47 a.m. revealed Resident R80 had a cup of medication and a cup of water with Miralax in it, and an inhaler left on the bedside table unattended. During an interview on 1/2/24, at 10:49 a.m. Licensed Practical Nurse (LPN), Employee E12 confirmed one capsule of 0.5mg Dutasteride (used in men to treat the symptoms of an enlarged prostate), one tablet of 1mg Folic Acid (vitamin B-9 supplement), one scoop of 17 gm Miralax (used to treat constipation) mixed in 8 ounces of water, a 2.5-2.5 mcg/act…

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, review of facility documents, and staff interviews, it was determined the facility failed to accurately track infections in the facility for one of six months (December 2023). Findings include: Review of the Infection Surveillance policy dated 2/21/23, indicated the purpose to track infections is to identify infections and to monitor adherence to recommend infection prevention and control practices in order to reduce infections and the prevent spread of infections. It was indicated all residents and infections will be tracked and monthly time periods will be used to capture and report data. Review of the facility's Monthly Facility Infection Analysis dated December 2023 was left blank and not completed. During an interview on 1/5/24, at 11:07 a.m. Infection Preventionist, Employee E13 confirmed the facility failed to actively track infections for December 2023. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 201.18 (b) (1) (e) (1) Management.