Julia Ribaudo Extended Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, laboratory reports, facility policy, and staff interviews, it was determined the facility failed to ensure a resident was free from unnecessary medication by administering an antibiotic without documented clinical evidence supporting an active infection for one of 20 residents reviewed (Resident 97).Findings Include:A review of Resident 97's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included epilepsy (a chronic neurological disorder characterized by recurring seizures) and parkinsonism (a group of neurological disorders that cause movement problems such as tremors, stiffness, and slowed movement). A review of the facility policy titled Antimicrobial Stewardship Program Policy, last reviewed by the facility on June 6, 2026, revealed antibiotics should be prescribed only when clinical evidence supports the presence of an active infection. The policy further revealed appropriate indications for antibiotic use include…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of select facility policy, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications for two of two medication carts observed (A Hall and B Hall medication carts).Findings include: Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals last reviewed by the facility [DATE], indicated that multi-use medication vials or bottles that have been opened or accessed (e.g. seal broken) are to be labeled with the date they were opened to ensure proper tracking for expiration purposes. An observation of the medication cart located on A hall unit on [DATE], at 8:56 AM, in the presence of Employee 2 RN (Registered Nurse) of the medication stored in the medication cart, revealed one (1) multi-dose insulin pen of Insulin glargine (a long acting insulin medication used to lower blood sugar) and one (1) multi-dose pen of Insulin Aspart (a fast short acting insulin medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, Centers for Disease Control and Prevention (CDC) guidance, staff interviews, clinical record review, and direct observation, it was determined the facility failed to establish, maintain, and implement an effective infection prevention and control program to prevent the spread of infections regarding animal visitation and indwelling urinary catheter maintenance for 2 of 6 sampled residents. (Residents 1 and 2). Findings include: A review of the facility's policy titled Infection Control Policies and Practices, last reviewed February 12, 2025, revealed it is the policy of the facility to maintain an organized, effective facility-wide program designed to systematically prevent, identify, control and reduce the risk of acquiring and transmitting infections among employees, volunteers, visitors and contract healthcare workers. The policy indicated that employees support resident safety by adhering to all policies and procedures related to infection prevention. A 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 a review of clinical records, resident council meeting minutes, and resident and staff interviews, it was determined the facility failed to provide an environment that promotes each resident's quality of life by ensuring residents' personal space was free from intrusions by other residents (Residents 16 and 19), including experiences reported by two residents out of the 25 residents sampled (Residents 3 and 29) and experiences reported by six out of the eight residents during a resident group interview (Residents 26, 28, 32, 49, 69, and 90). Findings include:A review of resident council meeting minutes dated May 27, 2025, revealed residents in attendance had concerns regarding one resident wandering into resident rooms. A review of the meeting minutes failed to determine if this concern was resolved. A review of resident council meeting minutes dated June 26, 2025, revealed residents in attendance had concerns regarding wandering residents. The minutes indicated the concerns for wandering residents were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident council meeting minutes, resident and staff interviews, and observations it was determined the facility failed to maintain an adequate supply of clean linens to meet the needs of residents for 2 of 4 resident care units observed (E Hallway and A Hallway). Finding include: Review of the Resident Council meeting minutes dated July 29, 2025, revealed residents expressed concerns regarding the availability of linens. The minutes further documented that the Nursing Home Administrator identified nurse aides were discarding washcloths, and the Administrator noted that a lot of linen had been ordered for staff to utilize while providing care to residents. Observations conducted on August 12, 2025, at approximately 11:00 AM in the E Hallway revealed one washcloth available for resident care. Additional observation of the A Hallway at approximately 11:15 AM on the same day revealed a linen cart containing only three bath towels and three washcloths available for resident care. Observations conducted on August 13, 2025, at 8:15 AM in the E Hallway revealed no washcloths and…

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

Based on a review of scheduled facility mealtimes, select facility policy, and resident and staff interviews, it was determined that the facility failed to consistently provide snacks as desired by residents, including experiences reported by four out of eight residents during a group interview (Residents 28, 32, 69, and 90). Findings include: A review of the facility policy titled Meal Times and Frequency Policy, last reviewed by the facility on February 1, 2025, revealed that it is the facility policy that there will be no more than 14 hours between a substantial evening meal (dinner) and breakfast the following day; except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal (dinner) and breakfast the following day if a resident group agrees to this meal span. A review of the facility's scheduled mealtimes revealed that the time between dinner and breakfast the next day exceeds 14 hours. Specifically, residents residing in the North Nursing Unit Area 1 are scheduled to receive dinner at 4:40 PM and receive breakfast at 7:10…

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

Based on observations, a review of facility-provided documents, and resident and staff interviews, it was determined the facility failed to maintain an effective pest control program on two of two nursing units (South Nursing B Hall and North Nursing D Hall) and in the North Nursing Resident Dining/Lounge area. In addition, two residents out of twenty-five sampled (Residents 62 and 81) and six residents out of eight during a resident group interview (Residents 26, 28, 32, 49, 69, and 90) reported ongoing problems with small black flies, gnats, or ants in resident rooms and common areas.Findings include: A review of a facility policy entitled Pest Control Policy that was last reviewed on February 1, 2025, indicated routine pest control procedures will be in place to prevent pest infiltration and contracted pest services will document all visits along with actions taken. A review of the facility's current contract with the pest management contractor signed and dated August 12, 2019, revealed year-round protection against pests (except for gnats, outdoor pests and other free flying…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and resident interviews, it was determined the facility failed to develop and implement a comprehensive, person-centered care plan that addressed the resident's individualized needs and interventions for safe transfers for one out of 25 residents sampled (Resident 22). Findings include: A clinical record review revealed Resident 22 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function) and anxiety disorder (a condition in which excessive worry causes clinically significant distress or impairment in social, occupational, or other areas of functioning). A physician's order indicated Resident 22 required the assistance of two staff members for transfers using the standing lift (mechanical device used to help a resident who has some weight bearing ability but cannot safely stand or transfer without assistance) initiated on January 14, 2025. A review of a quarterly Minimum Data Set assessment (MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of clinical records, documentation provided by the facility, and resident and staff interviews, it was determined that the facility failed to implement adequate safety measures to prevent accidents for two out of 25 residents sampled (Resident 62 and 63). Findings include: A review of facility policy titled Self-Administration of Medications, last revised June 2024, revealed the interdisciplinary team should assess and determine with respect to each resident whether self-administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition. The policy indicates that if it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan, the facility should routinely assess the residents cognitive, physical and visual ability to carry out this responsibility, and the resident should have a locked medication storage compartment in their room so that another…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policy, observations, and staff and resident interviews, it was determined the facility failed to ensure oxygen therapy was administered and maintained in accordance with physician orders and facility policy, including requirements for equipment labeling, dating, and routine maintenance, in a manner that minimized the risk for infection for two residents out of twenty-five sampled (Residents 3 and 62). Findings include: A review of the facility policy titled Oxygen Administration Policy, last reviewed by the facility on February 1, 2025, revealed it is the facility's policy that licensed clinicians with demonstrated competence will administer oxygen by way of the specified route as ordered by a provider. The policy indicates changing the humidifier bottle (containers attached to an oxygen concentrator to add moisture to the oxygen being delivered) when empty; length of use is dependent upon the liter flow setting (a measurement describing the amount of oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 select facility policy review and staff interview, it was determined the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for one resident out of 25 sampled residents (Resident 19). Findings include: A review of the facility's policy entitled Pain Management with a policy review date of February 1, 2025, indicated that non- pharmalogical interventions will be attempted prior to the admission of a PRN (as needed) medication, If the nonpharmacological interventions fail then with corresponding intensity ratings, the resident will be administered the medication ordered for the corresponding pain rating within the PRN order. A clinical record review revealed that Resident 19 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest that affects…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Pennsylvania's Nursing Practice Act, facility policies, clinical records, and facility investigative documents, and staff interviews, it was determined the facility failed to implement a physician's order as written for one of 8 residents reviewed (Resident 1). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated the registered nurse is responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with medical diagnoses that included depression and atrial fibrillation (a cardiac arrhythmia characterized by an irregular and often rapid heart rhythm). A physician's order dated October 2, 2024, was noted for Eliquis (blood…

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

Based on staff interview and review of professional literature, the facility's assessment, facility provided documentation, and review of the medical, psychiatric, and mental health conditions of the resident census, it was determined that the facility failed to conduct and document a facility-wide assessment, using evidence-based methods, which identified the specific resources necessary to care for its specific resident population. Findings include: Review of the Centers for Medicare and Medicaid Services Memorandum, Revised Guidance for Long-Term Care Facility Assessment Requirements (QSO-24-13-NH) dated June 18, 2024, revealed that the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. Continued review revealed, The assessment of the resident population…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 select facility policy, the facility's infection control log and staff interview, it was determined the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility. Findings included: A review of facility policy titled Infection Prevention and Control Program Policy last reviewed by the facility on December 15, 2023, indicated that the facility must maintain an organized, effective facility-wide program designed to systematically prevent, identify, control, and reduce the risk of acquiring and transmitting infections; conduct surveillance of communicable disease and infectious outbreaks; and monitor employee health. A review of the facility's infection control data revealed the facility's infection control program failed to reflect an operational system to monitor and investigate causes of infection and manner of spread. There was no evidence of a system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to provide appropriate treatment and services to restore normal bowel function for one out of 21 residents sampled (Resident 75). Findings include: A review of facility policy titled Continence Management Program, last reviewed by the facility on December 15, 2023, revealed the facility will ensure a plan designed to manage incontinence is developed according to the resident's needs and capabilities. The policy indicates residents should be considered for a bowel incontinence program for those who require limited to extensive assistance in toilet use or who could benefit from a prompted or scheduled toileting plan. The license nurse will complete a new continence evaluation once they identify a pattern. The licensed nurse will develop a toileting plan, determining the approaches needed to achieve the goals. A clinical record review revealed Resident 75 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 clinical records, select facility policy, observation, and staff interview, it was determined the facility failed to implement procedures to maintain records of controlled drugs and ensure accurate drug administration for one out of the 21 residents sampled (Resident 75) and failed to store drugs in a safe manner for one out of the 21 residents sampled (Resident 39). Findings include: A facility policy titled Long Term Care Facility Pharmacy Services and Procedures Manual 5.4 Inventory Control of Controlled Substance, last reviewed by the facility on December 15, 2023, revealed the facility should maintain separate individual controlled substance records on all Schedule II medications and any medication with a potential for abuse or diversion. The policy also indicates the facility should regularly check inventory records to reconcile inventory. The facility should regularly reconcile current inventory to the controlled medication declining inventory record and the resident's medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policies, investigative reports, and staff interviews, it was determined the facility failed to ensure that two residents out of 21 sampled (Residents 35 and 64) were free from abuse perpetrated by another resident (Resident 76). Findings include: A facility policy titled Pennsylvania Resident Abuse Section: Abuse, Neglect, and Exploitation, last reviewed by the facility on December 15, 2023, revealed the facility will not tolerate abuse by anyone. Abuse is defined as the willful infliction of injury, intimidation, or punishment, resulting in physical harm, pain, or mental anguish. The policy indicates that physical abuse includes hitting, slapping, punching, and kicking. Verbal abuse is defined as the use of language that willfully includes disparaging and derogatory terms directed at residents or their families, regardless of the resident's age, ability to comprehend, or disability. Furthermore, the policy states that willful means the individual must have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide adaptive dining equipment as required and prescribed for one resident out of 21 sampled (Resident 52). Findings include: A review of the clinical record revealed that Resident 52 was admitted to the facility on [DATE], with diagnoses to include early onset Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions) diagnosed before the age of 65, protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of protein and nutrients needed for health), and oropharyngeal dysphagia (swallowing problems occurring in the mouth and/or throat). Review of a Speech Therapy Discharge summary dated [DATE], revealed that Resident 52 was not able to self-control the rate and amount of food and liquids presented to him at meals. The resident was provided with a maroon spoon (an adaptive spoon with a narrow, shallow bowl)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews it was determined that the facility failed to ensure that one resident out of five sampled was free of chemical restraints used to most readily control the resident's behavior and not required to treat the resident's medical symptoms (Resident B1). Findings include: A review of Resident B1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included unspecified dementia (a group of symptoms that affects memory, thinking and interferes with daily life), unspecified psychosis (is the term for a collection of symptoms that happen when a person has a disconnection from reality and can occur due to different mental and physical conditions), and insomnia. An annual Minimum Data Set assessment (a federally mandated standardized assessment completed periodically to plan resident care) dated May 8, 2024, indicated that the resident was severely cognitively impaired with a BIMS (brief interview to assess cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews, it was determined that the facility failed to ensure residents had access to a telephone that afforded privacy for residents during telephone calls on two out of two resident units. Findings include: Observation of the Countryside nursing station on January 18, 2024, at approximately 10:50 AM revealed no telephones intended for resident use that afforded the residents privacy during telephone calls. Interview with Employee 1 (nurse aide) on January 18, 2024, at approximately 10:52 AM revealed that the residents may use the corded telephone located behind the nursing station. The resident may sit behind the nurses station or staff place the phone on the counter for the resident to reach. Employee 1 confirmed there is no area for the residents to have a private conversation while at the nurses station. Employee 1 explained that the facility previously had cordless phones for the residents use however the phones stopped working and they were never replaced. Observation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to timely notify the resident's interested representative of a change in condition for one resident out of 12 sampled (Resident A1). Findings include: A review of the clinical record revealed that Resident A1 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder ( is a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), diabetes and anxiety. A review of the resident's recorded monthly weights revealed that on November 7, 2023, the resident's weight was noted as 195 lbs. The resident's next recorded monthly weight was dated December 6, 2023, revealed that the resident's weight decreased to 171 lbs. The resident lost 24 lbs, a significant weight loss of 12% loss of body weight, in one month. A dietary note dated December 6, 2023, indicated 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 clinical records and staff interview, it was determined that the facility failed to consistently provide timely and necessary foot care for one of eight residents sampled (Resident A1). Findings include: Review of Resident A1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include diabetes and deep vein thrombosis (blood clot in a deep vein). Review of clinical records revealed Resident A1 was admitted to the hospital on [DATE]. A review of the hospital podiatry (foot doctor) consultation report dated December 22, 2023, at 12:00 PM, revealed that the reason for the consult was Nails in disarray. The report stated that the Patient has elongated nails with what looks like a traumatic avulsion of the right 4th nail. Elongated nails that appear painful for the patient. Elongated nails x 9 b/l LE (bilateral lower extremities) that are thickened and with subungual debris noted (debris under to toenails). Further review of the resident's clinical…

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

Based on observations, clinical record review and resident and staff interview it was determined that the facility failed to provide services necessary to maintain adequate personal hygiene of residents who need assistance with activities of daily living for three out of 8 residents reviewed. (Residents 1, 2 and 3). Findings include: A review of Resident 1's clinical record revealed admission to the facility on December 1, 2023, with diagnoses of cerebral infarction (stroke). The resident was cognitively intact and admitted for short term therapy services. A review of the resident's clinical record and initial care plan revealed no evidence of the resident's shower or bathing schedule or preferences. A review of the facility's shower schedule binder revealed that Resident 1 was to receive a shower on Wednesdays during the 7 AM. to 3 PM shift and Saturdays on the 3 PM to 11 PM. A review of the resident's bathing record conducted during the survey of December 20, 2023, revealed that Resident 1 was showered only once since her admission to the facility on December 1, 2023. 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.

Based on a review of clinical records, resident, family and staff interviews it was determined that the facility failed to provide care in a manner and environment that promotes each residents' quality of life by failing to respond timely to residents' requests for assistance, which negatively impacted the residents' quality of life in the facility as evidenced by three of 8 residents interviewed (Residents 1, 6, and 7). Findings include: A review of Resident 1's clinical record revealed admission to the facility on December 1, 2023, for short term rehab therapy services with diagnoses of cerebral infarction (stroke). The resident was assessed as cognitively intact. During an interview on December 20, 2023, at approximately 12:30 PM, Resident 1 and her husband stated that she has waited from 30 minutes up to an hour for staff to respond to her call bell and provide assistance when requested. Resident 1 stated that these long waits for staff to respond to her requests for assistance have occurred multiple times since her admission to the facility at the beginning of the month. She…

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

Based on observation and staff interview, it was determined that the facility failed to ensure the facility was free from potential accident hazards and obstacles to safe mobility assistance devices. Findings include: According to §483.90(i)(3) Facilities must equip corridors with firmly secured handrails on each side of the corridor (Secured handrails means handrails that are firmly affixed to the wall). An observation of the E hallway on December 20, 2023 at 10 A.M. and again at 1 P.M. revealed 3 rollator walkers, 5 wheelchairs, a resident room arm chair, a stool and a large linen cart were lined up blocking access to the handrails on the right side of the corridor. These items completely obstructed resident access to the hand railing on the right side of the hallway. Observations at that time revealed multiple residents self-propelling in wheelchairs in the hallway. During an interview December 20, 2023 at 1:30 P.M. the Nursing Home Administrator confirmed that the handrails on the right side of hallway were obstructed and that residents did not have unimpeded access 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.

Based on a review of facility policy and clinical records, observations, and staff interview it was determined that the facility failed to ensure the consistent implementation of infection control practices designed to prevent the spread of scabies. Findings include: A review of facility policy entitled Scabies Management Policy last reviewed on September 7, 2023, indicated it is the policy of the facility to treat residents infected with and sensitized to scabies and to prevent the spread of scabies to other residents and staff. Scabies is spread by skin to skin contact with the infected area or through contact of bedding, clothing, privacy curtains and some furniture. The diagnosis may be established by recovering the mite from its burrow and identifying it microscopically. Failure to identify scrapings as positive does not exclude the diagnosis. It is difficult to obtain a positive scraping because only one or two mites can cause multiple lesions. Often diagnosis is made from signs and symptoms and treatment followed without scrapings. Affected residents should remain on contact…

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