Abbeyville Skilled Nursing And Rehabilitation Cent

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Review of the facility documents and staff interview, it was determined that the facility failed to permit a resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility for one of six residents (Resident R1).Findings include: Review of the facility policy, Discharge Planning Process dated 10/20/24, indicated the facility must develop and implement an effective discharge planning process. Included in the process description was, Include regular evaluation of patients to identify changes that require modifications of the discharge plan' the discharge plan must be updated to reflect these changes. Review of the American Medical Association Code of Medical Ethics document, Physician Responsibilities for Safe Patient Discharge from Healthcare Facilities indicated, To facilitate a patient's safe discharge 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.

Based upon review of facility policy and procedure, clinical record review, and staff interview it was determined the facility failed to ensure the physician was notified of a weight gain for two of 32 residents reviewed (Resident 76 and Resident 147). Findings include: Review of facility policy and procedure titled Weights and Heights, revised 2023, revealed the facility is to notify the physician and dietitian of significant weight changes; document notification of physician and dietitian in the Weight Change Progress Note and the licensed nurse will notify the physician of the dietitian recommendations. Review of Resident 76's physician orders revealed an order stating weigh - daily. Notify MD with weight gain of 1 pound in 1 day or 3 pounds in one week. Review of Resident 76's Weight Summary revealed on January 21, 2025 Resident 76 weighed 226.5 pounds. Further review of Resident 76's Weight Summary revealed on January 22, 2025 Resident 76 weighed 230 pounds indicating a 3.5 pound weight gain in one day. Review of Resident 76's clinical record failed to reveal evidence that…

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

Based on review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure a complete and thorough investigation of an incident involving suspected abuse for one of 31 residents reviewed (Resident 78). Findings include: Review of facilities Abuse Prohibition policy, revision date October 24, 2022, states employees are designated as mandated reports and are obligated to immediately report any reasonable suspicion of a crime against a patient. Review of minimum data set (MDS, standardized assessment tool to evaluate residents) dated October 1, 2024, revealed Resident 78 possessed a brief interview for mental status (BIMS) of 14 out of 15 (cognition intact). Clinical record review for Resident 78 revealed nursing documentation dated October 6, 2024, at 8:21 PM that indicated that staff were notified by Resident 78 that she/he was hit multiple times by a staff member during the evening shift (3pm-11pm) on October 6, 2024. Further review of nursing documentation revealed the following [Resident 78] made false accusations…

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

Based on clinical record review and staff interview, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed for two of 31 residents reviewed (Resident 60 and Resident 92). Findings include: The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. Review of Resident 60's clinical record revealed the resident was readmitted to the facility on August, 2025. Subsequent review of Resident 60's clinical record failed to produce a copy of a completed PASRR. A request for a copy of a completed PASRR was request from 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.

Based upon clinical record review, it was determined the facility failed to ensure a baseline care plan was in place for a Foley catheter (rubber tube placed into bladder to drain urine out of the body) upon admission for one of 32 residents reviewed (Resident 84). Findings include: Review of Resident 84's clinical record revealed Resident 84 was admitted to the facility with a Foley catheter on January 14, 2025. Review of Resident 84's care plan failed to reveal evidence of a care plan for Resident 84's Foley catheter. Interview with the Nursing Home Administrator on February 6, 2025 at 11:07 a.m. confirmed that there was no baseline care plan completed from admission regarding Resident 84's Foley catheter. 28 Pa. Code 211.12(d)(5) Nursing Services 28 Pa. Code 211.5(f) Clinical Records

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical records review, and staff interview, it was determined the facility failed to ensure interventions were provided timely for a resident at risk for developing a pressure ulcer and that wound monitoring was done timely for one of three residents reviewed. (Resident CL1). Findings include: A review of the facility's policy titled Skin Integrity and Wound Management, revised on October 15, 2024, revealed, that the plan of care for the patient will reflect assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan as needed. The same policy revealed the identification of the patient's skin integrity status and the need for prevention or treatment intervention through a review of all appropriate assessments and information. Implement pressure injury prevention for identified modifiable risk factors. A review of Resident CL1's admission assessment 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 the facility's policy, Pennsylvania Department of Health (DOH) 2023-PAHAN-694 review, clinical records review, observations, and staff interviews, it was determined the facility failed to ensure that infection control prevention and management were implemented on two of four units observed ([NAME] and [NAME]) as well as within reception and Rehab department. Findings include: Review of the Pennsylvania Department of Health 2023-PA HAN-694-5-11- UPD (updated) titled Interim Infection Prevention and Control Recommendation for COVID-19 in Healthcare Settings, updated on May 11, 2023, revealed Department of Health (DOH) recommends using the following additional infection control prevention and control practices related to COVID-19 (An infectious respiratory illness caused by the SARS-CoV-2 virus), along with standard practice recommended as a part of routine healthcare delivery to patients. The same PA HAN revealed source control options for HCP (healthcare personnel): A NIOSH-approved particulate…

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

Based on review of clinical records, pharmacy delivery report, and staff interview, it was determined the facility failed to ensure the physician's medication order was followed for one of the three residents reviewed (Resident CL1). Findings include: Review of Resident CL1's physician order dated November 23, 2024, revealed an order for Rytary Oral Capsule Extended Release 23.75-95 MG (Carbidopa-Levodopa) Give 3 capsules by mouth three times a day for Parkinson's (A disorder of the central nervous system that affects movement, often include tremors). Review of the November 2024 Medication Administration Record (MAR) revealed that from November 24, 2024, until November 30, 2024, Resident CL1 was not administered with medication Rytary nine times. Nursing progress notes review dated November 24, 2024, at 9:23 a.m., 11:56 a.m., and 7:00 p.m., November 28, 2024, at 9:17 p.m., November 29, 2024, at 10:22 p.m., November 30, 2024, at 1:12 p.m., all indicated that medication was not administered pending/awaiting delivery from the pharmacy. Review of the pharmacy medication delivery report…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 upon clinical record review and interview, it was determined the facility failed to establish a baseline care plan upon admission for a surgical wound for one of one resident reviewed (Resident 1). Findings include: Resident 1's clinical record review revealed Resident 1 was admitted to the facility on [DATE], for short term rehabilitation from surgery. Review of Resident 1's care plan failed to reveal evidence that a baseline care plan was established upon admission for the presence and care of a surgical wound. Interview with Licensed Employee E1 on August 13, 2024, at 10:24 a.m. confirmed Resident 1 did not have a baseline care plan established upon admission for the presence and care of a surgical wound. Interview with the Interim Director of Nursing on August 13, 2024, at 12:30 p.m. confirmed Resident 1 did not have a baseline care plan established upon admission for the presence and care of a surgical wound. 28 Pa. Code 211.11(c)(d) Resident Care Plan

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon clinical record review and interview, it was determined the facility failed to provide bathing/showering services for one of one resident reviewed (Resident 1). Findings include: Resident 1's clinical record review revealed Resident 1 was admitted to the facility on [DATE], for short term rehabilitation from surgery. Review of Resident 1's clinical record failed to reveal evidence that Resident 1 received a shower from admission through August 13, 2024. Interview with Licensed Employee E1 on August 13, 2024, at 10:24 a.m. confirmed Resident 1 had not had a shower since admission on [DATE]. This interview further confirmed that there was no clinical reason for Resident 1 not to have received a shower. Interview with the Interim Director of Nursing on August 13, 2024 at 12:30 p.m. confirmed Resident 1 had not received a shower since admission. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services Previously cited 8/16/2023, 3/8/2024, 4/30/2024, 6/11/2024

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon clinical record review and interview, it was determined the facility failed to assess a surgical wound for signs and symptoms of infection for one of one resident reviewed (Resident 1). Findings include: Resident 1's clinical record review revealed Resident 1 was admitted to the facility on [DATE], for short term rehabilitation from surgery. Further review of Resident 1's clinical record revealed Resident 1 had a surgical wound located mid-back. Review of Resident 1's physician orders upon admission revealed an order indicating, Surgical incision on back - cleanse incision with NSS [normal saline], dry well and leave OTA [open to air] every day shift for incision care. Review of Resident 1's June 2024 Treatment Administration Record revealed the above-mentioned treatment did not occur on June 22, 2024, and June 23, 2024. Review of Resident 1's progress notes dated July 1, 2024, revealed Pt [patient] seen for c/o [complaints of] infection to surgical back incision. [resident] has reported an increase…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of the facility's policy, clinical records facility documentation review, and staff interview, it was determined that the facility failed to thoroughly and timely investigate an allegation of being mishandled with roughness by a resident who verbalized feeling of not being safe in the facility for one of two residents reviewed (Resident CL1). Findings include: Review of the facility's policy titled Abuse Prohibition, review date October 24, 2022, revealed that immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, initiate an investigation within 24 hours of an alleged of abuse that focuses on whether abuse or neglect occurred and to what extent; clinical examination for signs of injuries if indicated; causative factor; and interventions to prevent further injury. The investigation will be thoroughly documented within the Risk Management Portal. Ensure that documentation of witnessed interviews is located. Review of Resident CL1'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews it was determined that the facility failed to ensure a safe and sanitary environment for one of the two units observed ([NAME]) Findings include: Observation in Resident R1's room conducted on June 11, 2024, at 10:45 a.m., revealed a multiple black pellet-looking object approximately 20 plus on the bottom wall vent and approximately 50 on the floor below the resident ' s television. Observation of room [ROOM NUMBER] bathroom conducted on June 12, 2024, at 10:50 a.m., revealed three tiles were broken exposing a hole in the bottom wall of the bathroom. Interview with licensed nurse, Employee E3 was conducted with the above observations on June 11, 2024, at 11:00 a.m. Employee E3 confirmed that the multiple black pellets-looking objects in resident 1's room were mouse droppings. Observation conducted on June 11, 2024, at 1:30 p.m., revealed the mouse droppings observed earlier were still present in the resident's room. Interview conducted with the maintenance director on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview and staff interviews, it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one of two residents reviewed (Resident R1). Findings include: Review of Resident R1's admission progress note of April 3, 2024, revealed that the resident was admitted with a surgical wound to the right lower leg with a wound VAC (vacuum assisted closure - therapeutic technique using a suction pump, tubing, and a dressing to remove excess exudate [fluid] and promote healing in acute or chronic wounds) in place. Review of a physician's order dated April 3, 2024, indicated wound vac - do not change dressing - monitor dressing and machine - res [resident] sees trauma and acute care for wound vac changes - notify trauma and acute changes if any issues every shift for wound care. Review of Resident R1's progress note of April 24, 2024, revealed that resident tested positive for Flu A and Flu A…

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

Based on observation and interview, it was determined that the facility failed to have an effective pest control system on the facility's dementia unit (Arcadia). Findings include: Interview with Employee E4 on April 10, 2024, at 12:00 p.m. revealed mice were a big issue on the dementia unit, and that seeing mice running around day and night was a common occurrence. Tour of the Arcadia unit on April 10, 2024, at 12:00 p.m. revealed mouse droppings on the nightstand next to Resident 1's bed. Interview with Resident 2 on April 10, 2024, at approximately 12:15 p.m. revealed that the resident frequently sees mice running around the unit and the room, and the last time the resident saw a mouse was the prior night running around the resident's room. Review of pest control logs revealed the facility's pest control company last came to the facility on March 29, 2024. Interview with the Nursing Home Administrator on April 10, 2024, at approximately 2:30 p.m. confirmed the facility was aware of an ongoing mice problem. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(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 clinical record review and staff interview, it was determined that the facility failed to ensure that written notices of emergency transfers to the hospital were provided to the Office of the State Long Term Care Ombudsman for 6 of 24 residents reviewed (Resident 78, 111, 112, 119, 126 and 146). Findings include: Review of Resident 78's clinical record revealed Resident 78 was hospitalized on [DATE] and was readmitted to the facility on [DATE]. No documentation was provided indicating the Office of the State Long Term Care Ombudsman was notified. Review of Resident 111's clinical record revealed Resident 111 was hospitalized on [DATE] and was readmitted to the facility on [DATE]. No documentation was provided indicating the Office of the State Long Term Care Ombudsman was notified. Review of Resident 112's progress note of October 28, 2023, revealed that the resident wanted to go to the hospital. The on-call physician was notified and ordered that the resident be sent to the hospital. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and staff interview, it was determined that the facility failed to follow acceptable infection control practices related to proper ice handling on 3 of 4 units ([NAME], [NAME], and Roosevelt). Findings include: Observation on March 5, 2024, at 11:25 a.m. on [NAME] unit revealed that the ice scoop was in a covered plastic container. The container had a washcloth placed in the bottom with the ice scoop resting directly on the washcloth which was wet. Observations on March 8, 2024 between 10:05 a.m. and 10:07 a.m on the [NAME] unit and Roosevelt unit, respectively, revealed that the ice scoops were in covered plastic containers. The containers had a washcloth in the bottom with the ice scoop resting directly on the washcloth in approximately one inch of water. Interview with the DON and Employee E4, Infection Preventionist, on March 8, 2024, at 1:30 p.m., confirmed that the washcloth should not be in the container with the ice scoop. 28 Pa Code 201.18(b)(3) Management 28 Pa. Code 211.12…

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

Based on a review of clinical records and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for one of 32 residents reviewed (Resident 79). Findings include: Review of Resident 79's clinical record revealed a quarterly Minimmal Data Set (MDS- a tool used to identify plan of care) dated December 1, 2023, identified a new pressure ulcer. Further review of Resident 79's clinical record revealed no further documentation of the pressure ulcer. An interview with the licensed employee E3, on March 8, 2024, at 9:49 a.m., revealed that the resident did not have a pressure ulcer during the review for the MDS, and it was incorrectly coded. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, clinical records review, and staff interviews, it was determined that the facility failed to ensure residents with an order for fluids restrictions were monitored for their fluid intake for three of the 32 residents reviewed (Residents 76, 108, and 124). Findings include: Review of Resident 76's physician orders revealed an order for Fluid restriction 1800 ml daily [milliliters] Further review of Resident 76's clinical records failed to reveal documented evidence that Resident 76's fluid restrictions were monitored according to physician's orders. Clinical records review revealed Resident 108 was readmitted from the hospital on January 16, 2024, with a diagnosis of Hyponatremia (low sodium level). Review of the physician order dated January 18, 2024, revealed an order for Fluid restriction 1800/24 hrs. Review of Resident 108's clinical records failed to reveal Resident 108's fluid intake was monitored from January 18, 2024, until February 1, 2024. Review of Resident 124's physician orders revealed an order for Fluid restriction 2000 ml [milliliters] daily.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical records review and staff interview it was determined that the facility failed to provide respiratory service and treatment for one of the 32 residents reviewed (Resident 42). Findings include: Review of Resident 42's diagnosis list includes Obstructive sleep apnea (Which means breathing stops for short periods during sleep due to a blocked/partially blocked airway). Observation conducted on March 6, 2024, revealed a CPAP (Continuous positive airway pressure - A machine that uses mild air pressure to keep breathing airways open while you sleep) machine on Resident 42's bedside table. Review of Resident 42's physician's order sheet dated November 21, 2022, revealed an order for CPAP @ pressure 15cm H2O every night shift for Sleep Apnea. Review of Resident 42's clinical records revealed Resident 42 was hospitalized on [DATE], due to Acute Encephalopathy (An acute/subacute functional alteration of mental status due to systemic factors) and returned to the facility on January 4, 2024.…

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

Based on clinical record review, pharmacy record review, and staff interview it was determined the facility failed to ensure medications were available for residents for two of the 32 residents reviewed (Resident 42, and 85). Findings include: Review of Resident 42's physician order dated September 3, 2023, revealed an order for Linezolid Oral Tablet (antibiotic) 600mg one tablet by mouth every 12 hours for UTI (Urinary Tract Infection). Review of Resident 42's September 2023 Medication Administration Record (MAR) revealed Linezolid ordered on September 3, 2023, was not administered to the resident until the evening of September 5, 2023. Review of the pharmacy delivery report revealed Resident 42's Linezolid medication ordered on September 3, 2023, was not delivered to the facility until September 5, 2023. Review of Resident 85's nursing progress notes dated January 19, 2024, revealed resident was observed with redness and swelling to the left eye, the NP (nurse practitioner) was notified and ordered Erythromycin ointment (eye antibiotic) to the left eye and Prednisone tablet.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication manufacturer's guidelines, and staff interviews, it was determined that the facility failed to ensure medications were properly stored and labeled for two of the three units observed ([NAME] and [NAME]). Findings include: Review of the facility's policy titled Storage and Expiration Dating of Medications, Biologicals, dated January 2022, revealed that once a medication or biological package is opened, the facility should follow manufacturer/supplier guidelines concerning the expiration date for opened medication. Facility staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened. The same policy also revealed that the facility should ensure that the medications are stored in the containers in which they were originally received. Review of the manufacturer's storage guidelines for Insulin Lispro (Humalog-fast-acting insulin), revealed that the medication must be stored at room temperature…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide the necessary services to maintain personal hygiene for residents unable to carry out activities of daily living for one of three residents reviewed (Resident 1). Findings include: Interview with Resident 1 on August 14, 2023, at 1:20 p.m. revealed that resident does not receive a bed bath as scheduled. Review of Resident 6's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated June 21, 2023, indicated that the resident was cognitively intact and resident is totally dependent on one person for assistance with bathing. Review of facility documentation revealed that resident is to receive a shower/bath on Wednesdays and Saturdays. Review of documentation from July 14, 2023, to July 14, 2023, revealed that the resident did not receive a shower/bath. Interview with the Director of Nursing (DON) on August 15, 2023, at 2:00 p.m. indicated that the resident had received bed baths, but sometimes refuses.…

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