Buffalo Valley Lutheran Villag

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 assess and implement individualized interventions to promote bowel continence for one of two residents reviewed for incontinence (Resident 7).Findings Clinical record review revealed a quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) assessment dated [DATE], that staff assessed Resident 7 as continent of his bowel. Further review of Resident 7's clinical record revealed an MDS assessment completed on April 3, 2025, noting staff assessed Resident 7 as now occasionally incontinent of bowel, and a significant change MDS completed on June 30, 2025, revealed staff assessed Resident 7's bowel continence declining to now being frequently incontinent of bowel. Interview with the Director of Nursing and Nursing Home Administrator on September 26, 2025, at 1:37 PM revealed the facility did not have a policy addressing bowel continence. Review of Resident 7's plan 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.

Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure medication security for two of 18 residents reviewed (Residents 4 and 62).Findings include: The facility policy entitled, Discarding and Destroying Medications, last reviewed without changes on April 7, 2025, revealed that non-controlled and Schedule V (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications. Should the facility contract with a DEA-registered collector, controlled substances may be disposed of in an authorized collection receptacle located at the facility. Both controlled and non-controlled substances may be disposed of in the collection receptacle. For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the steps include mixing the medication (either liquid or solid) with an undesirable substance (to include sand, coffee grounds, kitty litter,…

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, staff interview, and review of facility documentation, it was determined that the facility failed to maintain an effective pest control program so that the facility is free from pests in the main kitchen area.Findings include: Observation of the facility's main kitchen on September 23, 2205, at 9:03 AM with Employee 6, dietary manager, revealed the following: The wall of the dishwashing area contained multiple black colored, winged, smaller insects. At least four were observed on the wall. A concurrent interview with Employee 6 revealed that these insects have been present for at least one and a half weeks and the facility placed traps to help remedy the insects. Further observation of the main part of the kitchen revealed multiple additional black colored, winged insects located on the ceiling next to a vent. The ceiling area adjacent to the vent had unidentified splash stains. A large spider was observed walking across the floor in the area that held the heated meal delivery carts and proceeded to enter a floor drain. The above information was reviewed in a…

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

Based on a review of select facility policies and procedures, facility grievance log documentation, clinical record review, and family and staff interview, it was determined that the facility failed to make a prompt effort to resolve resident grievances for one of six residents reviewed (Resident 1). Findings include: The facility policy entitled, Resident Grievance Report and Tracking Log, last reviewed April 7, 2025, revealed that the facility, upon receiving a concern or grievance, would actively seek a resolution and keep the resident/health care agent appropriately apprised of the findings towards resolution. Upon receipt of a grievance or concern, the community staff member receiving the grievance or concern will immediately initiate a Resident Concern/Grievance Report. All pertinent data will be gathered and documented to promptly investigate, follow through, and provide timely resolution to the grievance/concern. Resolution will be communicated to the resident, health care agent or surrogate, and documented on the Resident Concern/Grievance Report. The grievance officer will…

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 select facility policies and procedures, clinical record review, and staff and family interview, it was determined that the facility failed to thoroughly investigate and report to the appropriate agencies an incident of potential resident abuse for one of six residents reviewed (Resident 1). Findings include: The facility policy entitled, Abuse/Neglect Prevention and Response, last reviewed April 7, 2025, revealed that an allegation of potential or actual abuse, neglect, or exploitation will be immediately reported to the appropriate leadership and government agencies, the resident protected, and the allegation investigated. The definition of abuse includes willful intimidation with resulting pain or mental anguish. Physical abuse is defined as hitting, slapping, pinching, kicking, and the like. It also includes controlling a resident's behavior through physical punishment and/or intimidating behaviors such as shaking a finger in a resident's face. It is the facility's responsibility to investigate each concern that is raised and it is the Administrator who is…

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

Based on a review of select facility policies and procedures, clinical record review, and resident family and staff interview, it was determined that the facility failed to ensure that a physical restraint was used for the treatment of medical symptoms for one of six residents reviewed (Resident 1). Findings include: The facility policy entitled, Abuse/Neglect/Mistreatment of Residents/Misappropriation of Resident Property, last reviewed without changes on January 25, 2025, revealed that the facility standard is that the facility protects each resident's right to be free from abuse, neglect, mistreatment or misappropriation of property through appropriate screening, training, prevention, identification, investigation, protection, and reporting/response procedures. Physical abuse includes, but is not limited to, hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. Prevention includes that through training, the facility will reinforce with employees their responsibility to identify, correct, and intervene in situations in which…

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 select facility policies and procedures, clinical record review, and family and staff interview, it was determined that the facility failed to thoroughly investigate resident incidents and implement individualized interventions to prevent falls for one of seven residents reviewed for fall concerns (Resident 7). Findings include: The facility policy entitled, Fall Management, last reviewed without changes on January 25, 2024, revealed that the definition of a fall includes that unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. The purpose of the procedure is to provide assessment, after care, and identify new interventions to prevent further falls. As soon as possible after caring for the resident, the nurse will complete an Incident and Investigation Report and a Post Fall Investigation form. Staff document pertinent information regarding the fall in the resident's electronic health record. Interview with Resident 7's sister on August 27, 2024, at 10:26 AM revealed that Resident 7 fell…

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, observation, and staff, resident, and family interview, it was determined that the facility failed to implement interventions, consistent with physician orders and resident preferences, for two of two residents reviewed for nutrition and hydration concerns (Residents 43 and 66). Findings include: Interview with Resident 43 on August 27, 2024, at 11:28 AM revealed that he was to abide by a physician ordered fluid restriction. Resident 43 stated that he was not sure how much fluid he was allowed and, they (staff) take care of it. Clinical record review for Resident 43 confirmed that the physician ordered an 1800 ml (milliliter) fluid restriction within which dietary would provide 360 ml per each day shift meal. Interview with Resident 43 during observation of the lunch meal on August 27, 2024, at 1:19 PM revealed that he did not receive milk as per his meal tray ticket. Resident 43 stated that he requested cranberry juice and milk. Review of Resident 43's tray ticket confirmed that he circled cranberry juice and milk as his beverage choices. 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 clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by three of three residents reviewed (Residents 52, 60, and 79). Findings include: Clinical record review for Resident 52 revealed the facility admitted her on February 24, 2021. A diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) was added on November 8, 2022. A review of Resident 52's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated July 3, 2024, indicated that the facility assessed Resident 52 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 52's care plan revealed that there was no indication that the facility had developed and implemented 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 clinical record review and staff interview it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medication for one of five residents selected for medication regimen review (Resident 7). Findings include: Clinical record review for Resident 7 revealed a physician order dated March 13, 2024, for staff to administer Zyrtec (allergy medication) 10 mg (milligrams) by mouth one time a day for, .cold and runny nose. A consultant pharmacist review dated April 5, 2024, requested that the physician evaluate the need for Resident 7's continued daily use of Zyrtec. The physician accepted the recommendation with the direction to reassess the need for the medication in two weeks. Resident 7's clinical record contained no evidence that staff reassessed Resident 7's need for the Zyrtec medication after two weeks. The physician order for Resident 7's Zyrtec remained active until it was discontinued on July 3, 2024. A review of Medication Administration Records (MARs, electronic documentation of the administration of…

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

Based on clinical record review and staff and family interview, it was determined that the facility failed to ensure that the resident and the resident representative received written notice that specified the duration of the bed-hold policy for one of seven residents reviewed for hospitalizations (Resident 7). Findings include: Interview with Resident 7's sister on August 27, 2024, at 10:29 AM revealed that Resident 7 had been to the hospital. Resident 7's sister stated that all communication from the facility regarding the hospitalization was verbal, and she did not receive any written notices. Clinical record review for Resident 7 revealed nursing documentation dated June 28, 2024, at 8:45 PM that staff found Resident 7 on the floor in her room. Staff assessed swelling to Resident 7's forehead, notified the physician, and obtained instructions to send her to the emergency department for testing. The documentation noted, RP (responsible party) aware and gave verbal request for bed hold. The surveyor requested evidence of written information to Resident 7's responsible party that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set assessments for two of 19 residents reviewed (Residents 2 and 88). Findings include: Review of Resident 88's closed clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated May 29, 2024, that indicated the facility indicated that Resident 88 was discharged from the facility to a hospital setting. Nursing documentation dated May 29, 2024, at 10:58 AM indicated that Resident 88 was discharged home with her husband. Interview with the Administrator and Director of Nursing on August 29, 2024, at 10:26 AM confirmed that Resident 88's discharge location was coded in error on the MDS dated [DATE]. Review of Resident 2's clinical record revealed an MDS dated [DATE], that indicated that staff assessed Resident 2 as being on an antibiotic. Further review of Resident 2's clinical record revealed no evidence…

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 resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered weight assessments for one of 19 residents reviewed (Resident 43). Findings include: Interview with Resident 43 on August 27, 2024, at 11:36 AM revealed that he often has swelling of his lower extremities and weight gain due to fluid retention. Resident 43 stated that he is to abide by a physician ordered fluid restriction. Clinical record review for Resident 43 revealed active physician orders as follows: Fluid restriction, 1800 ml (milliliters) related to congestive heart failure (inefficient ability of the heart to pump blood and oxygen through the body; causes blood and fluids to collect in inappropriate areas like the lungs and legs over time) Lasix (Furosemide, diuretic medication used to remove excess fluid from the body) oral tablet 80 MG (milligrams) by mouth one time a day related to acute and chronic respiratory failure (insufficient oxygenation of the body) Physician orders instructed staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide physician ordered services to maintain a resident's range of motion for one of five residents reviewed (Resident 23) and failed to provide services to maintain a resident's range of motion for one of five residents reviewed (Resident 40). Findings include: Clinical record review for Resident 23 revealed a current physician's order dated October 15, 2023, where occupational therapy indicated that staff should place a palmar roll (foam cushioning) on her right hand every evening at bedtime (HS) for contracture prevention. Resident 23 was to wear the palmar roll per her tolerance at HS with staff completing skin checks each shift while the palmar roll was worn. There was no documentation available that indicated staff placed the palmar roll nightly or completed skin checks while the palmar roll was placed. Observation and concurrent interview with Resident 23 on August 27, 2024, at 10:12 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interview, it was determined that the facility failed to receive informed consent and assess for the risk of side rail entrapment for two of six residents reviewed for accident hazards (Residents 12 and 66). Findings include: Observation of Resident 12's room on August 27, 2024, at 9:57 AM and August 28, 2024, at 10:53 AM revealed that there were bilateral one-quarter enabler bars (side rails) on the bed. Clinical record review for Resident 12 revealed a nursing enabler bar assessment dated [DATE], that indicated Resident 12 was assessed by therapy for enabler bars. Therapy indicated that Resident 12 did not need enabler bars. On August 13, 2024, maintenance staff evaluated the one-quarter enabler bars on Resident 12's bed and indicated that they passed for potential entrapment. There was no documentation that indicated the facility received consent from Resident 12 or their responsible party to utilize enabler bars, that the facility provided education to…

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

Based on review of facility staff education records and staff interview, it was determined that the facility failed to ensure that all nurse aide staff completed a minimum of 12 hours of in-service education training each year for two of three nurse aides reviewed (Employees 1 and 2). Findings include: During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on August 28, 2024, at 1:00 PM the surveyor requested evidence of annual in-service education for Employee 1, nurse aide, hired January 10, 2017, and Employee 2, nurse aide, hired June 5, 2023. Interview with the NHA on August 29, 2024, at 12:20 PM confirmed that Employee 1 only completed 7.25 hours and Employee 3 only completed 9.0 hours of the required 12 hours of annual in-service education, which included dementia training, abuse prevention training, and any areas of weakness or resident special care needs in the past year. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.20(a)(d) Staff development 28 Pa. Code 211.12(c) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store and prepare food in a safe and sanitary environment in the facility's main kitchen. Findings include: Observation of the facility's main kitchen on August 29, 2023, at 10:05 AM with Employee 4, chef, revealed the following: A foot pedal garbage inside the entrance of the kitchen to the preparation area was covered in dried debris and dried food splatter on the exterior of the can. The exterior door and sides of an upright ice cream freezer contained dried food and food splatter. The backsplash of the stove was observed covered with dried food splatter, which extended to the walls behind the stove area, the sides of the stove, and the lower shelf of a preparation table to the left of the stove. Two kettle units to the right of the stove were observed with dried food on the sides of the kettle, back, and sides of the base of the kettle stand. The tilt kettle was observed with dried food on the sides and back of the tilt kettle. The flooring under the stove, kettles, and tilt kettle had…

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 facility failed to provide a written notice of the facility's bed hold policy to the resident or responsible party for two of six residents reviewed for hospitalizations (Resident 50 and 81). Findings include: Review of Resident 81's clinical record revealed that the facility sent him to the hospital on June 29, 2023. There was no documented evidence in Resident 81's clinical record to indicate that the facility provided him, or his responsible party written information on the facility's bed hold policy. Clinical record review for Resident 50 revealed the resident was sent to the hospital on June 28, 2023, and admitted . There was no evidence to indicate Resident 50's responsible party was provided written information on the facility's bed hold policy. Interview with the Administrator and Director of Nursing on August 31, 2023, at 12:12 PM confirmed the above findings for Resident 81 and 50. 483.15(d) Notice of bed-hold policy and return Previously cited 9/30/22 28 Pa. Code 201.14(a) Responsibility 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 clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two of two residents reviewed (Residents 3 and 32). Findings include: Review of Resident 3's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated March 10, 2023, indicating that the facility assessed him as being on an antibiotic. Resident 3's MDS dated [DATE], also indicated that the facility assessed him as being on an antibiotic. Review of Resident 3's clinical record revealed no documented evidence of his physician ordering an antibiotic during the lookback time frames for his March 10, 2023, and June 6, 202,3 MDS. Interview with the Administrator and Director of Nursing on August 31, 2023, at 9:32 AM confirmed that Resident 3's MDS's were coded in error for using an antibiotic. Review of Resident 32's clinical record revealed an annual MDS dated [DATE], indicating…

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 facility failed to provide treatment and care for the prevention of skin excoriation for one of one resident reviewed for skin concerns (Resident 23). Findings include: Review of a consultant wound evaluation for Resident 23 dated August 1, 2023, revealed the resident had MASD (MASD, moisture associated skin damage, excoriation of the skin due to prolonged exposure to feces, urine, or perspiration) that measured 0.6 cm (centimeter) x 0.3 cm. The wound was improved as evidenced by the decreased surface area. House barrier cream (protective skin care such as Calmoseptine ointment) was to be applied once daily for 16 days. Review of the TAR (TAR, treatment administration record) for Resident 23 dated August 8 through 21, 2023, revealed that Calmoseptine ointment was applied to the sacrum (low back) area daily for 14 days then the physician indicated to reassess for a new treatment. Review of a consultant wound evaluation for Resident 23 dated August 15, 2023, revealed the consultant signed off from 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 observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for two of two residents reviewed for respiratory care (Residents 309 and 310). Findings include: Observation of Resident 309 on August 29, 2023, at 11:28 AM revealed a continuous positive airway pressure (CPAP, a machine used during sleep to keep the airway open) machine in the resident's room. A concurrent interview revealed the resident utilized the CPAP, every night. An opened gallon container of distilled water was also noted. The container did not have an opened date on the bottle. Observation of Resident 309 on August 30, 2023, at 11:24 AM revealed a CPAP mask draped across the top drawer of the resident's bedside dresser. The mask was not bagged or protected from contamination from the ambient environment. The opened container of distilled water still did not have an opened date marked on it. Observation of Resident 309 on August 30, 2023, at 12:28 PM revealed the CPAP mask was still draped across 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 observation, clinical record review, and resident and staff interview, it was determined that the facility failed to assess for risk of side rail entrapment and review the risk and benefits of side rail utilization with the resident or resident representative for two of 11 residents reviewed for accident hazards (Residents 70 and 309). Findings include: Observation of Resident 70 on August 29, 2023, at 2:16 PM revealed the resident's bed had bilateral side rails. A concurrent interview revealed the resident was not aware why the side rails were on the bed, for safety, I think. Clinical record review for Resident 70 revealed no informed consent, assessment for risk of side rail entrapment, or a review of the risks and benefits of side rails with the resident. Documentation for Resident 70 titled Enabler Evaluation, that was dated August 28, 2023, at 1:37 PM revealed an evaluation form that noted that side rail replacement recommendations were marked as none, and side rail placement was documented as Side Rails / Assist Bar are not indicated at this time. 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.

Based on review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure nurses demonstrated competency in skills necessary for resident care for three of four staff reviewed for bladder scanning competencies (Employees 1, 2, and 3; Resident 14). Findings include: Review of a physician's order dated June 22, 2022, through July 29. 2023, for Resident 14 revealed the nurse was to perform a bladder scan (a device that measures an approximate volume of urine within the bladder, to determine if the bladder needs emptied when a person cannot empty the bladder to prevent kidney damage and/or infections) every shift and if the amount was greater than 250 ml (milliliters), the nurse was to straight catheterize the resident. If having to straight catheterize the resident frequently, get a urology (a physician who specializes in medical illness related to the urinary tract, i.e., bladder, kidneys, and associated area) appointment. Review of a physician's order dated July 29, 2023, from August 20, 2023, for Resident 14 revealed…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regimen was free from potentially unnecessary medications for one of five residents reviewed (Resident 14). Findings include: Clinical record review for Resident 14 revealed the resident had a diagnosis of unspecified dementia without behavioral disturbance, psychotic (out of touch with reality) disturbance, mood disturbance, and anxiety. Review of a physician's order for Resident 14 dated July 20, 2023, revealed the nurse was to administer lorazepam (a controlled substance prescribed for anxiety) 1 mg (milligram), give 0.25 tablet orally two times a day for agitation and anxiety and 0.25 tablet every six hours as needed for agitation and anxiety. Review of the August MAR (MAR, medication administration record) for Resident 14 revealed the resident received as needed Ativan (brand name for lorazepam) on August 3, 5, 6, 8, 9, 10, 11, and 15, 2023. Clinical record review for Resident's 14 revealed there was no physician's order limiting the timeframe 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 observation, clinical record review, and resident family and staff interview, it was determined that the facility failed to arrange for routine dental care to the extent covered under the State plan for one of two residents reviewed for dental concerns (Resident 50). Findings include: Clinical record review for Resident 50 revealed the resident was admitted to the facility on [DATE]. An observation of Resident 50 on August 29, 2023, at 11:40 AM revealed the resident had natural teeth and some buildup was observed on the resident's teeth. A family member present in Resident 50's room at the time of the observation indicated she was not aware of the resident being offered or receiving dental services since he was admitted to the facility. The family member noticed the resident needed a dental cleaning, and indicated the resident was always very good about receiving dental care routinely prior to residing at the facility. Further clinical record review for Resident 50 did not reveal any evidence 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.