Kittanning Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, facility documents, clinical records, incident investigations, and staff interviews, it was determined that the facility failed to ensure that residents are free from misappropriation of property for one of two residents (Resident R88).Findings include: Review of the facility policy Pennsylvania Resident Abuse dated 6/18/25, indicated that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Exploitation was defined as the unfair treatment or use of a resident or the taking of a selfish or unfair advantage of a resident for personal gain, through manipulation, intimidation, threats or coercion. Review of the clinical record revealed that Resident R88 was admitted to the facility on [DATE]. Review of Resident 88's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/12/25, indicated diagnoses of high blood pressure, thyroid disorder, and chronic pain. Review of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents' medication regime was free from unnecessary psychotropic (a mind-altering medication) medication for two of five residents (Resident R2 and R9).Findings include:Review of facility Psychotropic Medication Use policy dated 6/18/25, indicated all medications used to treat behaviors must have a clinical indication to be used. As needed, medications shall be limited to 14 days and cannot be renewed unless the attending physician evaluates the resident for the appropriateness of that medication. The physician must document rationale for medication for more than 14 days.Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE].Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/25, indicated diagnoses of high blood pressure, bipolar disorder (a mental condition marked by alternating periods of elation 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, review of personnel files, and staff interview, it was determined that the facility failed to properly screen an employee by failing to conduct a criminal background check prior to the start of employment for one of five personnel files reviewed (Licensed Practical Nurse (LPN) Employee E9).Findings include: Review of facility policy Abuse, Neglect and Exploitation dated 6/18/25, indicated it is the policy of the Facility to undertake background checks of all employees and to retain on file applicable records or current employees regarding such checks. Review of the facility Payroll/Human Resources Coordinator job description indicated an essential function of the position is to ensure that pre-screening of employees is completed (license verification, exclusion checks, background checks, drug screen/physical as required). Maintain complete employee files with accurate and up-to-date information. Review of LPN Employee E9's personnel file revealed a hire date of 9/25/25. Review of the personnel file did not include a completed state criminal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, reports submitted to the State, and staff interview it was determined that the facility failed to report an incident of neglect for two of five residents (Resident R71, and R88). Findings include: Review of facility Pennsylvania Resident Abuse policy dated 6/18/25, indicated all reports of resident abuse, neglect, misappropriation of resident property are reported immediately to the administrator, Director of nursing, and to the applicable state agency. Review of the clinical record indicated Resident R71 was admitted to the facility on [DATE]. Review of Resident R71's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/8/25, indicated diagnoses of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), Parkinson's Disease (a degenerative brain disease that affects muscle control, among other symptoms), 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 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, including bed hold policy for two of four residents sampled with facility-initiated transfers (Residents R1 and R5). Findings include:Review of facility policy Discharge Planning dated 6/18/25, indicated transfers and discharges will meet requirements. The facility will take steps to ensure that the transfer or discharge is documented in the resident's medical record and necessary information is communicated to the receiving health care institution or provider.Review of facility policy Bed Hold Letter dated 6/18/25, indicated it is the policy of the facility to track bed hold days and notify appropriate parties via bed hold letter.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…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to provide care and treatment as ordered by physician for one of three residents (Residents R71).Findings include: Review of the clinical record indicated Resident R71 was admitted to the facility on [DATE], with diagnoses of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), Parkinson's Disease (a degenerative brain disease that affects muscle control, among other symptoms), and depression. Review of Resident R71's care plan dated 4/22/25, indicated the resident has Parkinson's disease and to provide drug therapy per order. Review of Resident R71's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/8/25, indicated diagnoses were current. Review of Resident R71's Neurology after visit summary dated 11/19/25, revealed the resident was ordered to increase 20 mg (milligrams) entacapone…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive resident-specific plan of care for a resident with limited mobility requiring equipment and assistance to maintain or improve mobility for one of two residents (Resident R10). Review of facility policy Splint Issuance Policy dated 6/18/25, indicated that the patient splint schedule will be communicated to the multidisciplinary team and documented in the care plan. Review of the clinical record revealed that Resident R10 was admitted to the facility on [DATE]. Review of Resident 10's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/12/25, indicated diagnoses of hemiplegia (paralysis on one side of the body), cerebral vascular accident (a loss of blood flow to the brain, which damages brain tissue). Review of Resident R10's clinical record revealed a physician's order dated 9/5/25, to wear resting hand splint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, reports submitted to the State, and staff interview it was determined that the facility failed to make certain each resident received adequate supervision which resulted in a resident ingesting a skin cleanser for one of four residents (Resident R71).Findings include: Review of the facility Resident Incident and Accident Report policy dated 6/18/25, indicated an incident is any occurrence that is not consistent with routine care of a particular resident. Review of the clinical record indicated Resident R71 was admitted to the facility on [DATE]. Review of Resident R71's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/8/25, indicated diagnoses of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), Parkinson's Disease (a degenerative brain disease that affects muscle control, among other symptoms), 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, resident clinical record, and staff interview, it was determined that the facility failed to maintain a complete record of pre and post dialysis assessments for one out of three sampled resident records (Resident R11). Findings include: The facility Hemodialysis care policy last reviewed 6/18/25, indicated that communications between the dialysis provider and the facility staff will occur before and after each dialysis appointment. Document the assessment in the dialysis communication tool. Review of Resident R11's admission record indicated she was originally admitted on [DATE] and re-admitted to the facility on [DATE]. Review of Resident R11's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 11/5/25, indicated she had diagnoses that included congestive heart failure (a progressive heart disease affecting pumping action of the heart muscles impacting circulation, swelling and shortness of breath), diabetes (metabolic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete annual performance evaluations at least once every 12 months for two of five nurse aide (NA) personnel records (NA Employees E11 and E19).Findings include: Review of NA Employee E11's personnel record indicated a hire date of 7/1/23. Review of NA Employee E11's personnel record failed to include an annual performance evaluation at least every 12 months as required. Review of NA Employee E19's personnel record indicated a hire date of 7/1/23. Review of NA Employee E19's personnel record failed to include an annual performance evaluation at least every 12 months as required. During an interview on 1/7/26, at 1:45 p.m. Regional Nurse Consultant Employee E1 confirmed that the facility failed to complete annual performance evaluations at least once every 12 months for two of five nurse aide personnel records (NA Employee E11 and E19). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.19(2) Personnel records.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to ensure a resident received appropriate behavioral health services to maintain the highest practicable well-being as required (Resident R99).Findings include: The facility Psychotropic Medication Use policy last reviewed 6/18/25, indicated the facility should involve the resident or the resident representative in the discussion of potential non-pharmacologic and medication interventions to address the management of behaviors and the involvement should be documented in the resident's medical record. Review of the clinical record indicated Resident R99 was admitted to the facility on [DATE]. Review of Resident R99's active diagnoses revealed a history of suicidal ideations, dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), anxiety, and depression. Review of resident R99'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 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 R99).Findings include: Review of the clinical record indicated Resident R99 was admitted to the facility on [DATE]. Review of Resident R99's active diagnoses revealed a history of suicidal ideations, dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), anxiety, and depression. Review of resident R99's care plan dated 8/21/25, revealed the resident has behavioral symptoms due to anxiety. Interventions included to monitor and report any adverse side effects of medications, assess if anxiety endangers the resident and/or, others and to intervene as necessary, and obtain a psych consult/psychosocial therapy. Resident R99 care plan failed to include suicidal ideations. Review of Resident R99'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 facility policy, clinical records and staff interviews, it was determined that the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one of six residents (Resident R71).Finding include: The facility Medication Regimen Review (MRR) policy last reviewed 6/18/25, indicated that the drug regimen review of each resident is completed at least monthly by the consultant pharmacist and any irregularities are reported. Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the Director of Nursing to act upon recommendation contained in MRR. For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations and provide and explanations as to why recommendation was rejected.Review of the clinical record indicated Resident R71 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 policies, 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 one of five residents (Resident R2). Findings include:Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE].Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/25, indicated diagnoses of high blood pressure, bipolar disorder (a mental condition marked by alternating periods of elation and depression), and wound infection.Review of Resident R2's clinical record revealed physician orders for the following medications and failed to have a diagnosis for use of the medication:Tylenol (used to treat pain) 325 mg (milligram) every six hours - no diagnosis indicatedDocusate Sodium (used to treat constipation) 100 mg at bedtime - no diagnosis indicatedFamotidine (used to treat acid reflux) 20 mg daily - no diagnosis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for two of four quarters (January 2025 through March 2025 and July 2025 through September 2025).Findings include: A review of the QAA Committee meeting sign-in sheets from the period of January 2025 through March 2025, did not reveal that the Medical Director or Infection Preventionist were in attendance. A review of the QAA Committee meeting sign-in sheets from the period of July 2025 through September 2025, did not reveal that the Director of Nursing or Infection Preventionist were in attendance. During an interview on 1/9/25 at 10:33 a.m. Regional Nurse Consultant Employee E1 confirmed that the facility failed to conduct QAA meetings at least quarterly with all of the required committee members as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(e)(1)(2)(3)(4) Management.

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 provide accurate and timely documentation related to the COVID-19 (a respiratory disease) vaccine for two of five residents (Resident R83, and R95). Findings include:Review of facility policy Resident Vaccination dated 6/18/25, indicated that residents or their responsible party will be asked about prior vaccinations at admission. Prior doses of influenza, pneumococcal, COVID-19, and other vaccines will be documented in the immunization portal in the electronic health record. The Infection Preventionist will track resident immunizations and that vaccines are administered timely.Review of Resident R83's clinical record indicated the resident was admitted to the facility on [DATE].Review of Resident R83's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/24/25, indicated diagnoses of depression, chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 files and staff interview it was determined that the facility failed to conduct the minimum 12 hours of nurse aide (NA) training per year for one of five NA personnel records (NA Employee E11).Findings include: Review of NA Employee E11's personnel record indicated a hire date of 7/1/23. Review of NA Employee E11's personnel record revealed 4.67 hours of in-service education from 1/1/25 through 12/31/25. During an interview on 1/7/26, at 11:31 a.m. Regional Nurse Consultant Employee E1 confirmed that the facility failed to conduct the minimum 12 hours of nurse aide training per year for one of five NA personnel records (NA Employee E11). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a) Staff development.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, controlled medication shift reconciliation records and staff interviews, it was determined that the facility failed to implement procedures to promote accurate accounting of controlled medications on two of two medication carts reviewed (Unit One Medication Cart and Unti 2B Medication Cart) and failed to ensure accurate administration of medications, resulting in a medication error for one of five residents (Resident R1).Findings include:Review of facility policy Inventory Control of Controlled Substances dated 1/12/25, indicated facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily and document the results on a Controlled Substance Count Verification/Shift Count Sheet. Review of facility policy General Dose Preparation and Medication Administration dated 1/12/25, indicated prior to administration of medication, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for two of three residents reviewed (Residents R1 and R2).Findings include: Review of facility policy General Dose Preparation and Medication Administration dated 1/12/25, indicated prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including but not limited to the following:Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident.Confirm that the MAR (Medication Administration Record) reflects the most recent medication orderDocument the administration of controlled substances in accordance with applicable law.Document necessary medication administration/treatment information (e.g., when medications are opened,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure the physician was appropriately notified of missed medication doses for one of five residents reviewed (Resident R1). Findings include: Review of facility policy Medication Shortages/Unavailable Medications dated 1/12/25, indicated upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication is unavailable from pharmacy or a third-party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician/prescriber orders, as necessary. Review of facility policy Resident Change in Condition dated 1/12/25, indicated the physician/provider and resident/family/responsible party will be notified when there has been a need to alter the resident's medical treatment, including a change in provider orders. 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 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 one of five residents (Resident R1). Findings include: Review of facility policy Medication Shortages/Unavailable Medications dated 1/12/25, indicated upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication is unavailable from pharmacy or a third-party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician/prescriber orders, as necessary. Review of the clinical 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 2/19/25, indicated diagnoses of high blood pressure, depression, and personal history of malignant neoplasm of prostate (prostate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 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 R1). Findings include: Review of facility policy Medication Shortages/Unavailable Medications dated 1/12/25, indicated upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication is unavailable from pharmacy or a third-party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician/prescriber orders, as necessary. Review of the clinical 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 2/19/25, indicated diagnoses of high blood pressure, depression, and personal history of malignant…

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

Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly store, label and date food products in the Main Kitchen which created the potential for food borne illness. Findings Include: Review of the facility policy Storge of Refrigerated Foods last reviewed 1/12/25, and previously reviewed 1/2/24, indicated that employee lunches shall not be stored in dietary refrigerators. During an observation in the Main Kitchen Back Reach-in Cooler, on 1/12/25, at 9:35 a.m. an opened bottle of Pepsi, and an opened bottle of Dr. Pepper were observed with no name, or date. During an observation in the Main Kitchen Walk-in Freezer, on 1/12/25, at 9:37 a.m. an opened bag of mixed vegetables and an opened package of sausage patties had no date or label. During an observation in the Main Kitchen Dry Storage, on 1/12/25, at 9:45 a.m. an opened bag of corn flake cereal, had no label or date. During an interview completed on 1/12/24, at 9:55 a.m. Food Service Director Employee E10 confirmed the above observations and that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of three residents with facility-initiated transfers (Resident R21, R30, and R78). The findings include: Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE]. Review of Resident R21's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/6/24, indicated diagnoses of high blood pressure, hip fracture, and malnutrition (lack of sufficient nutrients to the body). Review of Resident 21's clinical record revealed that the resident was transferred to the hospital on [DATE]. Review of Resident R21's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 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 or therapeutic leave of absence (Resident R21, R30 and R78). Findings Include: Review of the facility policy Bed Hold Notice dated 1/12/25, and previously dated 1/2/24, indicated that the bed hold policy will be provided to residents at the time of transfer. In the case of an emergency, the paperwork should be provided within 24 hours. Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE]. Review of Resident R21's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/6/24, indicated diagnoses of high blood pressure, hip fracture, and malnutrition (lack of sufficient nutrients to the body). Review of Resident 21'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 clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed for three of three residents reviewed (Resident R4, R26, and R78). Findings include: Review of facility policy Medication Regimen Review dated 1/2/24, last reviewed 1/12/25, indicated the consultant pharmacist will provide the resident's MRRs to facility identified personnel who will ensure that the attending physician, medical director, director of nursing and other necessary facility staff receive the recommendations. The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. The facility should maintain readily available copies of the consultant pharmacists reports on file in the facility, and as part of the resident's permanent health record. Review of the clinical record indicated Resident R4 was admitted 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 observations, and staff interviews, it was determined that the facility failed to properly store medications in two out of two medications carts (2B and Unit 1 Medication Carts) and failed to properly store a medication on one of two medication rooms (Unit Medication Room). Findings include: During an observation on [DATE], at 10:16 a.m. of the 2B Medication Cart the following insulin pens failed to be stored correctly: -Resident R1's Insulin Glargine pen (prefilled pen used to help control blood sugar, insulin levels, and digestion) was not stored in a bag. -Resident R54's Insulin Glargine pen was not stored in a bag. -Resident R81's Insulin Glargine pen was not stored in a bag. During an interview on [DATE], at 10:22 a.m. Licensed Practical Nurse (LPN) Employee E15 confirmed the facility failed store Resident R1, R54, and R81's insulin pen correctly. During an observation on [DATE], at 10:23 a.m. Unit one medication cart was observed unlocked and one bottle of 81 milligram (mg) of aspirin and one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and 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 four residents (Resident R21, R87, and R199) Findings include: Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE]. Review of Resident R21's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/6/24, indicated diagnoses of high blood pressure, hip fracture, and malnutrition (lack of sufficient nutrients to the body). Review of Resident R21's clinical record revealed a physician's order dated 10/31/24, for nifedipine (a drug used to treat high blood pressure or chest pain). Review of this order for Resident R21 did not include a diagnosis for use of this drug. Review of Resident R87's admission record indicated the resident was admitted to the facility 11/15/24. A review of Resident R87's MDS dated [DATE], included 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, clinical records, and staff interviews, it was determined that the facility failed to make certain call bells were in reach for one of six residents as required (Resident R4). Findings include: The facility policy Call Lights dated 2/24/23, last reviewed 1/2/24, indicated it is the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room. The facility responds to residents needs and requests. Review of Resident R4's clinical record indicated admission to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/28/24, indicated diagnoses of hypertension (high blood pressure) polyneuropathy (disease that affects many nerves in the body) and depression. Review of Resident R4's care plan dated 1/17/24, indicated the resident was at risk for falling due to poor safety awareness. It was indicated to keep the call light in reach at all times.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, 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 one of two residents (Resident R87). Findings include: A review of the facility Resident Rights Regarding Treatment and Advance Directives dated 1/12/25, and previously dated 1/2/24, indicated that Advance Directives will be discussed with resident or their representative to determine if any Advance Directives have been chosen or of the resident has any questions. Review of Resident R87's admission record indicated the resident was admitted to the facility 11/15/24. A review of Resident R87's Minimum Data Set (MDS - periodic assessment of care needs) dated 11/21/24, included diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and morbid obesity due to excess calories. A 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.

Based on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of three sampled residents (Resident R47). Findings include: During observations on 1/14/25, at 9:54 a.m. Resident R47's bed was found with red substance on his sheets and red substance on the floor next to his bed. During an interview on 1/14/25, at 9:55 a.m. Licensed Practical Nurse (LPN) Employee E4 confirmed that the facility failed to maintain a safe, clean, and home-like environment for Resident R47 as required. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management

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 abuse in the required timeframe one of four residents (Resident R80). Findings include: Review of facility policy Review of facility policy Abuse, Neglect, and Exploitation dated 1/2/24, last reviewed 1/12/25, indicated all allegations of abuse, neglect, involuntary seclusion, injuries of unknown source, and misappropriation of resident property must be reported immediately to the Administrator, Director of Nursing, and to the applicable State Agency. All serious incidents involving a resident will be reported to the Department of Health (State Agency) field office within 24 hours. Review of the clinical record indicated Resident R80 was admitted to the facility on [DATE]. Review of Resident R80's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/22/24, indicated diagnoses of anemia (too little iron in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of three residents (Resident R30). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated the following instructions: - O0110K1, Hospice care: code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. Review of the clinical record indicated Resident R30 was admitted to the facility on [DATE]. Review of Resident R30's MDS dated [DATE], indicated diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four residents (Resident R4). Findings include: Review of facility policy Comprehensive Care Planning dated 1/2/24 indicated the resident care conference meets as scheduled to discuss each resident, review the previous care plan and to finalize the development of the current care plan. Adjustments are made by the interdisciplinary team to ensure that all programs and identified category of needs are addressed and that the plan is oriented toward preventing a decline in functioning. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/29/24, indicated diagnoses of high blood pressure, Bipolar Disorder (a mental condition marked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy and documents, resident interviews, 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 five weeks (12/10/24 through 12/21/24, and 12/26/24 through 1/16/25). Findings include: Review of facility policy Activities dated 1/12/25, and previously dated 1/2/24, indicated the facility is to provide an ongoing resident-centered Life Enrichment Program, based on comprehensive assessments and care plans will be provided. The program will be designed to meet the interests (including hobbies and cultural preferences) and the abilities of each resident including as their physical; mental; emotional; social; spiritual; psychosocial and leisure needs. The program will create opportunities for each resident to have a meaningful life by supporting his/her domains of wellness (security, autonomy, growth, connectedness, identity, joy, and meaning). The choices, previous positive lifestyles, 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 record review, observations, and staff interviews, it was determined that the facility failed to monitor and ensure proper treatment of resident wounds and complete weekly skin assessments for two of four (Resident R4, and Resident R199). Findings include: Review of facility policy Skin and Wound Care Best Practices dated 1/2/24, and last reviewed 1/12/25, indicated the licensed nurses will complete a Weekly Skin Check. This review is in addition to the nursing assistant's shower sheet skin reviews. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/29/24, indicated diagnoses of high blood pressure, Bipolar Disorder (a mental condition marked by alternating periods of elation and depression), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of a progress note dated 4/11/24,…

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 records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment and monitoring for pressure ulcers for two of three sampled residents (Residents R1 and R199). The facility Pressure injury prevention and treatment policy dated 1/2/24, and last reviewed 1/12/25, indicated that residents will be assessed for pressure injury risk on admission. Monitoring will be at least weekly, and an evaluation of the pressure ulcer/pressure injury will be documented. All assessments will include location/stage, size, pain, wound bed and appearance. Review of Resident R1's admission record indicated she was admitted on [DATE]. Review of Resident R1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 11/7/24, indicated that she had diagnoses that included Peripheral vascular disease (PVD-a progressive narrowing of the blood vessels impacting blood flow to the limbs),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility documentation, resident interview, review of clinical records and staff interview, it was determined that the facility failed to assess residents for smoking safety for one of two residents (Resident R52). Findings include: Review of the facility policy Resident Smoking dated 1/12/25, and previously dated 1/2/24, indicated that during the admission process, nursing will ask residents if they smoke or have a desire/intent to smoke while in the facility. Anyone answering yes is further assessed for smoking safety awareness and the need for reasonable physical or safety accommodations. The assessment is completed thereafter on readmission, quarterly, and with any significant change in the resident's condition. Review of the facility Smoking List, provided on 1/12/25, indicated that Resident R52 was a current smoker. Review of clinical record revealed that Resident R52 was originally admitted to the facility on [DATE]. Review of Resident R52's clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical records, facility policy and staff interview, it was determined the facility failed ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of one resident receiving hemodialysis (Resident R45). Findings include: A review of the facility Hemodialysis Care Policy dated 8/24/23, reviewed 1/12/25, indicated medications will be administered as ordered by the provider. A review of the facility Resident Change in Condition Policy dated 6/27/24, indicated the licensed nurse will recognize and intervene in the event of a change in resident condition. The physician will be notified as soon as the nurse identified the change in condition and the resident is stable. The physician must be notified when there is a significant change in the resident's physician condition. A review of Resident R45's clinical record indicated the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician visits were conducted at least every 60 days after the first 90 days of admission for one of nine residents reviewed (Residents R86) and failed to ensure a physician completed the initial visit for one of nine residents (Resident R201). Findings include: Review of Resident R86's clinical record indicated admission to the facility on 2/7/24. Review of Resident R86's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/13/24, indicated diagnoses of stroke (occurs when the supply of blood to the brain is reduced or blocked completely, which prevents brain tissue from getting oxygen and nutrients.) hypertension (high blood pressure) and dysphagia (difficulty swallowing). Review of Resident 86's clinical record revealed there was no documented evidence that Resident R86 was seen by a physician or physician delegate for 232 days between 2/7/24, and 9/25/24. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, controlled drug shift count record, and staff interview, it was determined that the facility failed to implement pharmacy procedures for the reconciliation of controlled drugs for one of three closed record residents reviewed (Closed Record (CR) Resident R96). Findings include: Review of facility policy Disposal/Destruction of Expired or Discontinued Medication dated [DATE], last reviewed [DATE], indicated destruction of controlled mediations should be documented on the controlled medication count sheet and signed by the registered nurse and witnessing licensed professional. Discontinued and unused medications of discharged or deceased residents shall be immediately removed from the medication cart and brought to nursing supervisory staff. Review of the clinical record indicated CR Resident R96 was admitted to the facility on [DATE]. Review of CR Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated [DATE], indicated diagnoses of Alzheimer's Disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies, clinical record review, and staff interview, it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary medications for two of four residents (Residents R4 and R78) and failed to identify a diagnosed specific condition for treatment for one of four residents receiving psychotropic medications (Resident R78). Findings include: Review of facility policy Psychotropic Medication Use dated 1/2/24, last reviewed 1/12/25, indicated psychotropic medications are drugs that affect mood, perception, or behavior, and include but are not limited to antipsychotics, anxiolytics, antidepressants, mood stabilizers or hypnotics. Psychotropic medications should only be prescribed to treat specific conditions as diagnosed and documented in the medical record. Review of facility policy Medication Regimen Review dated 1/2/24, last reviewed 1/12/25, indicated the consultant pharmacist will provide the resident's MRRs to facility identified…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent for two of five residents (Resident R24, and R47). Findings include: The facility's medication error rate was 6.67% (percent) based on 30 medication opportunities with two medication errors. Observation of a medication administration pass on 1/14/25, at 9:40 a.m. revealed Registered Nurse (LPN), Employee E4, failed to administer Resident R47's 305-700mg Potassium phosphate (medication used to make the urine more acidic, preventing kidney stones, as well as odor and rash) timely. Resident R47's medication was scheduled to be administered at 8:00 a.m. LPN, Employee E4 confirmed Resident R47's medication was late. Observation of a medication administration pass on 1/16/25, at 9:26 a.m. revealed LPN, Employee E1, failed to administer Resident R24's Adult 50 Plus 300mcg-250mcg multivitamin. LPN, Employee E15 confirmed the medication was not in stock and not administered as ordered. Interview with the Nursing Home Administrator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three residents (Resident R46). Findings include: Review of the facility Hospice Care Policy dated 5/24/23, and last reviewed 1/12/25, indicated the community provides hospice services through collaboration with a Medicare certified hospice agency when ordered by the resident's physician. Such services will be provided to meet professional standards and be provided timely. The facility will ensure the resident's written plan of care includes both the most recent hospice plan of care and description of the services furnished by the facility to attain and maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. The physician certification and recertification 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, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of four quarters (January 2024 through March 2024). Findings include: Review of facility policy Quality Assurance and Performance Improvement (QAPI) Program Policy dated 1/2/24, last reviewed 1/12/25, indicated the facility will maintain a QAPI Committee consisting, at a minimum of, the Administrator, the Director of Nursing Services, the Medical Director or his/her designee, the designated Infection Preventionist, Direct Care staff on a rotating basis, staff from ancillary departments on a rotating basis, and at least two other members of facility staff. A review of the QAPI Committee meeting sign-in sheets from the period of January 2024 through March 2024, did not reveal that the Nursing Home Administrator was in attendance. During an interview on 1/16/25 at 2:08 p.m. the Nursing Home Administrator confirmed that the…

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

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 develop care plans that included instructions to provide person centered care for bed mobility for three of four residents (Resident R2, R3, and R4). Findings include: Review of the facility Comprehensive Care Planning Policy last reviewed 1/2/24, indicated the facility must develop a comprehensive person centered care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and mental, and psychosocial needs that are identified in the comprehensive assessments. Review of Resident R2's admission record indicated she was admitted to the facility on [DATE], with diagnoses of anxiety, cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced), and mild intellectual disabilities. Review of Resident R2's Minimum Data Set (MDS-periodic assessment of a resident's abilities and 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 review of facility policy, clinical record, and staff interviews, it was determined that the facility failed to provide adequate assistance for bed mobility for one of four residents (Resident R1), which resulted in the resident falling out of bed and sustaining a 1.5 centimeter laceration to the upper cheekbone. Findings include: Review of the facility Fall Prevention and Management Policy dated 12/9/19, last revised 8/6/24, indicated residents are assessed for fall risk upon admission, quarterly, and as needed. It was indicated if risks are identified, preventive measure will be put in place and care planned. Review of the facility Comprehensive Care Planning Policy last reviewed 1/2/24, indicated the facility must develop a comprehensive person centered care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and mental, and psychosocial needs that are identified in the comprehensive assessments. Review of Resident R1's admission record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, resident representative concern, and facility documents, it was determined that the facility failed to provide a clean and homelike environment on two of three nursing units (Unit 1 and Unit 2). Findings include: Review of the facility policy Occupied Resident Room Cleaning Procedure dated 1/2/24, indicated that proper cleaning and disinfecting of environmental surfaces is necessary to break the chain of infection. Cleaning refers to the removal of visible soil from surfaces through the physical action of scrubbing with detergents/surfactants and rinsing with water. This step is to reduce the volume of organisms on a surface and remove foreign material that could interfere with disinfection. Occupied resident rooms will be cleaned daily to maintain a sanitary environment. Review of facility document Concern Form, dated 10/9/24, indicated that Resident R5 stated that her Room is filthy and needs cleaned. Review of facility document Concern Form, dated 10/11/2, indicated that Resident R1 stated that no one from housekeeping has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 grievances for 90 days, and resident and staff interviews, it was determined that the facility failed to effectively resolve and provide responses to residents and/or their responsible parties in a timely manner in relation to concerns documented via Grievance procedure and complete the reports in their entirety for four of seven grievances reviewed. Findings include: Review of facility policy Resident Grievances and Concerns Policy dated 1/2/24, indicated upon receipt of an oral, written, or anonymous grievance submitted by a resident, the Grievance Official will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated, if indicated. The grievance review will be completed in a reasonable timeframe consistent with the type of grievance (e.g., a concern regarding resident conduct will be addressed more quickly than a concern that involves activity programming or meals), but in no event will the review exceed thirty (30) days. If the Grievance Committee/Grievance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four residents (Resident R1). Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 1/2/24, indicated it is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation or residents, misappropriation of resident property and injuries of unknown source. If a staff member is accused or suspected of abuse the facility immediately remove staff member from resident care area and request a written statement from accused staff member. The person investigating the incident should interview the resident, the accused, and all witnesses and obtain written statements from the resident, if possible, the accused, and each witness. Evidence of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of 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 four residents (Resident R1). Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 1/2/24, indicated neglect is the 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. All allegations of abuse, neglect, involuntary seclusion, injuries of unknown source, and misappropriation of resident property must be reported immediately to the Administrator, Director of Nursing, and to the applicable State Agency. All serious incidents involving a resident will be reported to the Department of Health (State Agency) field office within 24 hours. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four residents (Resident R1). Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 1/2/24, indicated it is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation or residents, misappropriation of resident property and injuries of unknown source. If a staff member is accused or suspected of abuse the facility immediately remove staff member from resident care area and request a written statement from accused staff member. The person investigating the incident should interview the resident, the accused, and all witnesses and obtain written statements from the resident, if possible, the accused, and each witness. Evidence of the investigation should be documented. 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.

Based on a review of facility policy, facility documents, a resident interview, resident representative concern, and staff interview, it was determined that the facility failed to serve food products that appeared palatable for two meals. (Lunch 8/18/24, and Breakfast 10/1/24) Findings include: Review of facility policy Dining Experience at Mealtimes, dated 1/2/24, indicated that the facility will provide attractive, nourishing, and palatable meals. Review of facility document Concern Form, dated 8/18/24, indicated that Resident R2 had received burnt ham on lunch tray on 8/18/24, and Ham was black and tough. Review of a Resident Representative Concern dated 10/17/24, stated They served him burnt ham. It was ground up with black chunks in it and the lady across the hall was yelling about her food being burnt too. Review of facility document Concern Form, dated 10/1/24, indicated that Resident R3 stated that sausage on her breakfast tray on 10/1/24, was burnt. During an interview on 10/24/24, at 12:55 p.m. Resident R3 confirmed that she had made a complaint regarding burnt sausage 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 job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed effectively manage the facility to prevent the development and transmission of a communicable infection. Findings include: The job description for the Nursing Home Administrator specified the primary purpose of the job is to lead, direct, and manage the overall operations of the community in accordance with policies and procedures and current federal, state and local standards, guidelines and regulations that govern the community and to ensure the highest degree of quality care is maintained for each resident at all times. The job description for the Director of Nursing specified it is the responsibility of the DON to organize, develop, manage, and direct the overall operations of the Nursing Service Department in accordance with current federal, state and local standards, guidelines and regulations that govern the community. The DON is to work directly with the NHA and the Medical Director to ensure 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, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R2). Findings include: Review of facility policy Resident Communication System and Call Light Policy dated 1/2/24, indicated when the resident is in bed or confined to a chair, be sure the call light is within easy reach. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]/24. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/6/24, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking). During an observation on 9/11/24, at 11:14 a.m. Resident R2 was observed sitting on the edge of her bed. During this observation, Resident R2 stated, I'm not supposed to get up on my own, but how do they expect me to call for help when my call bell is 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 clinical records and staff interview, it was determined that the facility failed to notify the family of a change in condition in a timely manner for one of three residents (Resident R37). Findings include: Review of facility policy Resident Change in Condition, dated 1/2/24, indicated that the physician and Resident/Family/ Responsible Party will be notified when there has been a significant change in the resident's physical/emotional/mental conditions, and a need to alter the resident's medical treatment, including a change in provider orders. Review of the clinical record revealed that Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 8/27/24, indicated diagnoses of high blood pressure, dysphagia (difficulty swallowing), and chronic pain syndrome. Review of a Resident Representative concern dated 9/4/24, indicated that the Resident Representative was granted guardianship of Resident R37.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for one of three residents (Resident R38). Findings include: Review of facility policy Comprehensive Care Planning dated 1/2/24, indicated that the facility must develop a comprehensive Person-Centered Care Plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Review of Resident R38's admission record indicated he was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 8/7/24, included diagnoses of bipolar disorder (a mental condition marked by alternating periods of elation and depression), schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), 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 documents, facility policy, clinical records, facility tour, resident interview, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (leaving an area without permission) for one of 11 residents (Resident R38). Findings include: Review of facility policy Elopement/Unauthorized Absence last reviewed 8/2/24, indicated that the facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement the facility will implement its policies and procedures promptly to locate the resident in a timely manner. All residents will be assessed for the risk of elopement using the Elopement Observation on admission, quarterly, and as needed. Residents identified at risk will have interventions promptly implemented to reduce the risk of elopement. 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 record review, and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to offering the influenza vaccination for one of five residents (Resident R36). Findings include: Review of facility policy Resident Vaccination Policy dated 1/2/24, indicated influenza, pneumococcal, and COVID vaccination will be administered per provided orders. Consents/refusals/medical ineligibility will be documented in the electronic health record. 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 7/25/24, indicated active diagnoses of anemia (too little iron in the body), pneumonia (lung inflammation caused by bacteria or a viral infection), and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior). Section O0250 Influenza Vaccine 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 review of facility policy, clinical record, and staff interview it was determined that the facility failed to notify families of residents with positive COVID-19 (a contagious disease caused by a virus) test results in a timely manner for two of five COVID-19 positive residents (Residents R3, and R37.) Findings include: Review of the facility policy Guidance in Managing Respiratory Illnesses and Outbreaks dated 1/2/24, indicated that that upon identifying that residents have developed COVID-19, that the facility should notify residents and families. Review of the clinical record revealed that Resident R3 was admitted to the facility on [DATE]. Review of Resident R3 Minimum Data Set (MDS - periodic assessment of resident's care needs) dated 6/19/24, revealed diagnoses of high blood pressure, dysphagia (difficulty swallowing), and iron deficiency anemia (when blood does not have enough healthy red blood cells to carry oxygen throughout the body as a result of not enough iron). Review of Resident R3'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 facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccination for one of five residents (Resident R36). Findings include: Review of facility policy Resident Vaccination Policy dated 1/2/24, indicated influenza, pneumococcal, and COVID vaccination will be administered per provided orders. Consents/refusals/medical ineligibility will be documented in the electronic health record. 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 7/25/24, indicated active diagnoses of anemia (too little iron in the body), pneumonia (lung inflammation caused by bacteria or a viral infection), and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior). Review of Resident R36's clinical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 verbal abuse for four of four residents (Residents R2, R3, R4, and R5). Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 1/2/24, indicated it is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation or residents, misappropriation of resident property and injuries of unknown source. If a staff member is accused or suspected of abuse the facility immediately remove staff member from resident care area and request a written statement from accused staff member. The person investigating the incident should interview the resident, the accused, and all witnesses and obtain written statements from the resident, if possible, the accused, and each…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 verbal abuse for four of four residents (Residents R2, R3, R4, and R5). Findings include: Review of facility policy Abuse, Neglect, and Exploitation dated 1/2/24, indicated it is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation or residents, misappropriation of resident property and injuries of unknown source. If a staff member is accused or suspected of abuse the facility immediately remove staff member from resident care area and request a written statement from accused staff member. The person investigating the incident should interview the resident, the accused, and all witnesses and obtain written statements from the resident, if possible, the accused, and each witness. Review of the clinical record indicated 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 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 Comprehensive Care Planning dated 1/2/24 indicated the resident care conference meets as scheduled to discuss each resident, review the previous care plan and to finalize the development of the current care plan. Adjustments are made by the interdisciplinary team to ensure that all programs and identified category of needs are addressed and that the plan is oriented toward preventing a decline in functioning. Review of the clinical 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 5/13/24, indicated diagnoses of Cerebrovascular Accident (CVA - damage to the brain from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that a resident with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of four residents (Resident R1). Findings include: Review of American Society for Parental and Enteral Nutrition's (ASPEN) Nutrition Support Dietetics indicated confirmation of proper placement of tube should be performed via abdominal and chest x-ray. The placement of enteral devices should be performed or supervised by a physician proficient in such placement. Percutaneous enterostomy (gastrostomy or jejunostomy) tubes must be placed by a physician or under the guidance of a physician; subsequent replacement may be done by a health care professional or patient/caregiver proficient in such placement, as designated by the physician. Review of facility policy Enteral Nutrition dated 1/2/24, 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.

Based on review of facility policy, observations of resident areas and nursing units, resident council interview and staff interviews it was determined that the facility failed to make certain anonymous grievance forms were readily accessible for residents use throughout the facility for three out of three nursing units (100 unit, 200 unit, the Memory Impaired Unit). Findings include: The facility Resident grievance and concern policy dated 8/2018, and last reviewed 1/2/24, indicated that the facility recognizes that the residents have the right to voice grievances. Residents have the right to file a grievance anonymously. During a resident council group interview interview on 2/6/24, at 10:28 a.m. five out of six residents stated that they did not know how to complete an anonymous grievance form or where the forms would be located. During a tour with Maintenance Director Employee E8 on 2/6/24, at 11:19 a.m. the 100 unit common areas were observed without anonymous grievance forms available. During a tour with Maintenance Director Employee E8 on 2/6/24, at 11:21 a.m. the Memory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies, facility documents, and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential clinical duties for three out of 12 months. Findings include: Review of the facility policy Nutritionally High Risk resident Documentation, dated 7/20/21, and last reviewed 1/2/24, indicated that dietitians will review resident nutritional status and document monthly for nutritionally high risk residents. High risk residents include those with significant weight loss, pressure injury, and those using enteral nutrition (nutrition provided via a tube inserted into the intestines- used for people who cannot take food by mouth). Review of Dietitian's job description revealed that the dietitian will: · Monitor nutritional status of residents through the RAI assessment process (a means of ensuring that residents receive the highest quality of care and can maintain the highest quality of life) as assigned. · Assess 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.

Based on a review of facility policy, plans of correction, and the results of the current and former surveys, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: Review of the facility policy QAPI (quality Assessment/Performance Improvement) Plan, dated 1/2/24, indicated that the facility's vision is to focus on our goals and aspirations. It is the framework for our efforts to improve processes and care. A data review will be performed annually. Data may include, but is not limited to grievance logs, medical record review, skilled care claims, fall/incident and accident log, pressure ulcer lists, staffing trends, medication error reports and quality measures, survey outcomes. The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending 1/20/23, revealed that the facility would maintain compliance with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, resident council interview, and staff interview, it was determine that the facility failed to provide an active director for the Activities department for three out of 12 months (November 2023, December 2023, and January 2023). Findings include: The facility Life Enrichment program policy dated 5/4/23, last reviewed 1/2/24, indicated that an ongoing, resident-centered life enrichment program will be provided. The program will be designed to meet the interest and the abilities of each resident. The life enrichment director will involve residents in all aspects of program delivery and incorporate the resident's express interest. Review of Department staff listing on 2/5/24, indicated no assigned Activity Director personnel. Review of the February 2024 Activity calendar indicated a scheduled activity (balloon toss) for the residents on the locked dementia unit scheduled for 2/5/24, at 1:30 p.m. During an interview on 2/5/24, at 10:48 a.m. Activity assistant Employee E9 stated that there was not an Activities Director and she was 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, observations and staff interview it was determined that the facility failed to label/date opened medications on three of three medication carts (Medication Cart A, Medication Cart B, and the Memory Impaired Unit (MIU) Medication Cart). The facility failed to make certain that out-of-date medications were disposed of on one of three medication carts (Medication Cart B). The facility failed to secure controlled substances stored in the refrigerator utilizing double locks in one of two medication rooms (Unit 2A/2B Medication Room). Findings include: Review of facility policy Storage and Expiration Dating of Medications, Biologicals reviewed on 1/2/24, indicate that Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. If a multi-dose vial of an injectable medication has been opened or accessed the vial should be dated and discarded within 28 days unless the manufacture specifies a different date for that opened vial. When an ophthalmic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for one of four quarterly meeting (October 2023 through December 2023). Findings Include: The facility Quality Assurance and performance improvement program policy dated 3/17/23, and last reviewed on 1/2/24, indicated that the facility will maintain a QAPI committee consisting of the administrator, Director of nursing, Medical director, infection preventionist. The committee will meet on a regular basis, at least quarterly, to coordinate and evluate activities. Review of Quality assurance and performance improvement sign in sheets and attendance records from January 2023 through January 2024 did not include sign in documentation for meetings from October 2023 through December 2023. Additional review of documentation did not show evidence of the last quarterly meeting taking place. During an interview on 2/8/24, at 11:38 a.m. 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 facility policy, clinical record review, observation, and staff interview, it was determined the facility failed to implement measures to prevent the potential for cross contamination during a dressing change for one of three residents (Resident R238) and the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for five of 12 months (May 2023, June 2023, August 2023, September 2023, and October 2023). Findings include: Review of facility policy Infection Prevention and Control Program dated 1/2/24, indicated the particular focus of the program will be on conducting risk assessment, surveillance, reducing healthcare associated infections, limiting transmission of disease, immunization, promoting antibiotic stewardship, and reporting as necessary. It is our policy to maintain an organized, effective facility-wide program to systematically prevent, identify, control, and reduce the risk of acquiring and…

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

Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for five of twelve months (May 2023, June 2023, August 2023, September 2023, and October 2023). Findings include: Review of facility policy Antibiotic Stewardship Program dated 1/2/24, indicated as a component of the monthly Infection Prevention and Control Committee (IPCC) meeting the facility's use of antibiotics will be reviewed to include: monitoring/tracking of antibiotic prescribing, use, and resistance in order to promote a culture of optimal antibiotic use within the facility. The facility will review antibiotic utilization reports monthly from the Pharmacy that include type of drug prescribed (antibiotic name), number of days of treatment, and number of new starts of antibiotics. Review of the facility's Infection Control surveillance for February 2023, through January 2024, failed to include documentation to indicate that antibiotic monitoring was completed for May 2023, June 2023, August…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records, facility documents, and staff interviews, it was determined that the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) for one of three sampled resident records (Closed Resident Record CR7) Findings include: The facility Medicare cut-letter policy dated 8/24/23, indicated that the facility will assure all residents receive timely and appropriate notification of Medicare Non-Coverage (NOMNC) for services in accordance with State and Federal guidelines. Review of Closed Resident Record CR7's admission record indicated she was admitted on [DATE], with diagnoses that included dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and hyperlipidemia (elevated lipid levels within the blood). Review of Closed Resident Record CR7's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/1/23, 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.

Based on review of facility policy, observations, resident council interview, and staff interview, it was determine that the facility failed to provide scheduled activities on one of three nursing units (Memory impaired unit-MIU). Findings include: The facility Life Enrichment program policy dated 5/4/23, last reviewed 1/2/24, indicated that an ongoing, resident-centered life enrichment program will be provided. The program will be designed to meet the interest and the abilities of each resident. Review of the February 2024 Activity calendar indicated a scheduled activity (balloon toss) for the residents on the locked dementia unit scheduled for 2/5/24, at 1:30 p.m. The scheduled activity for 2/6/24 at 1:30 p.m. was bowling. During an interview on 2/5/24, at 10:48 a.m. Activity assistant Employee E9 stated that there is no Activities Director and she is the only activity staff in the facility since October 2023. During observations on 2/5/24, at 1:40 p.m. the locked dementia unit was found with five residents (Residents R60, R23, R52, R63; and Resident R14) sitting in the common…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the physician of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose) for one of three residents (Resident R13). Findings include: Review of facility policy Hypoglycemia Policy dated 1/2/24, indicated nursing personnel are responsible for recognizing signs and symptoms of hypoglycemia and responding accordingly. A blood glucose of 60 milligrams (mg) or less indicates the need for intervention. Give glucose gel (a medication used to raise blood sugar levels) if resident can tolerate oral intake. Repeat blood sugar every 15 minutes. Notify provider as soon as practicably possible. Document in medical record as appropriate. The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, and staff interview, it was determined that the facility failed to ensure that appropriate treatment and services were provided for one of three residents with a urinary catheter (Resident R71). Findings include: Review of facility policy Indwelling Urinary Catheter Care Procedure dated 1/2/24, indicated clinical staff with demonstrated competence may provide urinary catheter care. Such care will help to prevent catheter association urinary tract infections (CAUTIs) and prolong the life of the catheter system. Staff will check drainage tubing and bag to ensure that the catheter is draining properly, and no kinks are present. The urinary drainage bag must be placed below the bladder level but not on the floor. Ensure drainage bag is covered with privacy/dignity cover. Review of the clinical record indicated Resident R71 was admitted to the facility on [DATE]. Review of Resident R71'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 policies, clinical records, and staff interviews, it was determined that the facility failed to make certain that weights were monitored, and that weight loss was identified and addressed in a timely manner for two of five residents (Resident R21, and R38). Findings include: Review of facility policy Resident Weight, dated May 2015 and last reviewed 1/2/24, indicated that weights will be obtained routinely in order to monitor nutritional health over time. Each resident's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified, or as ordered. Review of the facility policy Nutritionally High Risk resident Documentation, dated 7/20/21, and last reviewed 1/2/24, indicated that dietitians will review resident nutritional status and document monthly for nutritionally high risk residents. High risk residents include those with significant weight loss, pressure injury,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that residents who were receiving enteral feedings (nutrition through a tube) received appropriate treatment and services to prevent potential complications for one of three residents (Resident R71). Findings include: Review of facility policy Enteral Nutrition last reviewed 1/2/24, indicated licensed clinicians with demonstrated competence may administer enteral feedings and provide tube/site care. Review of Title 42 Code of Federal Regulations (CFR) §483.25(g) indicated an enteral feeding tube may be associated with significant complications, including aspiration (when food or liquid goes into the airway instead of stomach). Aspiration risk may potentially be affected by factors such as diminished level of consciousness and improper positioning of the resident during administration of the feeding. Review of the clinical record indicated Resident R71 was admitted to 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.

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 maintain ongoing communication with the dialysis (a machine filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of one residents receiving dialysis (Resident R39). Findings include: Review of facility policy Hemodialysis Care dated 1/5/23, last reviewed 1/2/24, indicated communication between the dialysis provider and the facility staff will occur before and after each hemodialysis treatment and as needed. Document assessment in the Dialysis Communication Tool. Assessment includes vital signs, pre-treatment weight, medications administered before treatment, time of last meal, fluid intake, and any additional alerts or information. Review of the clinical record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39'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 facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to protect one of five residents (Resident R1) from neglect who was left unassessed after identification of a change in condition. Findings include: Review of the facility policy Abuse, Neglect and Exploitation dated 8/30/23, indicated that neglect is the failure of the facility, its employees or service providers, to provide goods and services to a resident to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility policy Resident Change in Condition, reviewed 12/6/23, and previously reviewed 1/6/23, indicated that the licensed nurse will recognize and intervene in the event of a change in resident condition. The nurse will address any emergency care required given the situation and then gather information prior to contacting the physician. The following should be included: current vital signs (blood pressure, temperature, pulse, respirations, 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, documents, and clinical records and staff interviews, it was determined that the facility failed to make certain that residents were free from physical abuse, and verbal abuse for four of 74 residents (Resident R1, R2, R3, and R4). This has been identified as past noncompliance. Findings include: The facility's policy Abuse, Neglect and Exploitation dated 1/5/23, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, and kicking, it also includes controlling behavior through corporal punishment. Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents. Examples of verbal abuse include but are not limited to threats of harm and saying things to frighten a resident. During an interview on 10/11/23, at 11:00 a.m., Social Worker Employee E1 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documents, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures to investigate allegations of physical and verbal abuse for three of 74 residents (Resident R1, R2, and R3). This has been identified as past noncompliance. Findings include: Review of the facility's Abuse, Neglect and Exploitation dated 1/5/23, stated that it is the facility ' s policy to investigate all allegations, suspicions, and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately begin an investigation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes…

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