St John specialty Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, resident record review, review of facility documents, and staff interview, the facility failed to provide an environment free from verbal abuse for one of three residents (Resident R400). Findings include: Review of facility policy Abuse, Prevention of Resident Abuse, Neglect, Mental Abuse, Reports of Theft, Exploitation and Misappropriation of Property dated 8/30/24, indicated that the facility will provide a safe and secure environment for all residents and will protect a resident's right to be free from any form of abuse, mental abuse, neglect, reports of theft, exploitation or misappropriation of property. Review of the clinical record revealed that Resident R400 was admitted to the facility on [DATE]. Review of Resident 400's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 9/3/24, indicated diagnoses of dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory), unspecified visual loss, and muscle weakness. Review of documentation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of four residents sampled with facility-initiated transfer (Residents R16 and R37). Findings include: Review of the clinical record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's MDS (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 9/3/24, indicated diagnoses of aftercare following joint replacement, urinary tract infection and hyperlipidemia (abnormally high levels of lipids or fats in the blood). Review of the clinical record indicated Resident R16 was transferred to hospital on 8/6/24 and returned to the facility on 8/14/24. Review of Resident R16's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and…

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 provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for one of four residents (Residents R16). Findings include: Review of the clinical record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 9/3/24, indicated diagnoses of aftercare following joint replacement, urinary tract infection and hyperlipidemia (abnormally high levels of lipids or fats in the blood). Review of the clinical record indicated Resident R16 was transferred to hospital on 8/6/24 and returned to the facility on 8/14/24. Review of Resident R16's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for the hospitalization on 8/6/24.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of four resident hospital transfers (Resident R16). Review of the clinical record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's MDS dated [DATE], indicated diagnoses of aftercare following joint replacement, urinary tract infection and hyperlipidemia (abnormally high levels of lipids or fats in the blood). Review of the clinical record indicated Resident R16 was transferred to hospital on 8/6/24 and returned to the facility on 8/14/24. Review of Resident R16's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for two of twelve residents (Residents R1, and R128). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of resident care needs), dated October 2024, indicated the following: Section A2105 Discharge Status: This item documents the location to which the resident is being discharged at the time of discharge. Select the two-digit code that corresponds to the resident's discharge status. Code 01, Home/Community: if the resident was discharged to a private home, apartment, board and care, assisted living facility, group home, transitional living, or adult foster care. A community residential setting is defined as any house, condominium, or apartment in the community, whether owned by the resident or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for one of five residents (Resident R29) to accurately reflect the current status of the resident and care needs. Findings include: Review of the facility policy Comprehensive Plan of Care dated 8/30/24 indicated specific individualized steps or approaches that staff will take to assist the resident to achieve the goals will be identified. These approaches serve as instructions for resident care and provide for continuity of care by all staff. Short and concise instructions should be written. Review of the admission record indicated Resident R29 admitted to the facility on [DATE]. Review of Resident R29's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/2/24, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), coronary artery disease (narrow arteries decreasing blood flow to heart), and heart failure (heart doesn't pump…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to provide appropriate care and services to maintain activities of daily living (ADLs) for communication for one of six residents (Resident R1). Findings include: Review of the facility policy Maintaining Respect and Dignity of the Resident dated 8/30/24, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. It was indicated residents shall be treated with dignity and respect at all times. Review of the facility policy Clinical Procedure Augmentative Communication Device dated 8/30/24, indicated communication boards and/or augmentative devices may be provided to individuals who are limited in their ability to communicate verbally but are able to communicate by using a device with pictures and/or words. The individual, speech therapist, or physician will identify a need for augmentative…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident had a physician order for care and management of an invasive catheter for one of one resident formerly on dialysis (Resident R122). Findings include: Review of facility policy Standards of Care dated 8/30/24, indicated a detailed care plan based on the resident's assessment, including specific interventions, goals, and responsible staff members. Ensure that all staff members are adequately trained in providing quality care, including specific skills needed for resident needs. Review of the admission record indicated Resident R122 was admitted to the facility on [DATE]. Review of Resident R122's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/8/24, indicated the diagnosis of anoxic brain damage (injury to the brain due to a lack of oxygen), renal insufficiency (condition where the kidneys lose the ability to remove waste and balance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review, and resident and staff interviews, and observations it was determined that the facility failed to provide a resident environment free of potential accidental hazards for one of five residents (Resident R30). Findings include. Review of the facility policy Resident Accidents/Incidents dated 8/30/24, indicated the facility will provide a safe and secure environment for residents and will be proactive in the prevention of accidents and incidents. Review of the admission record indicated Resident R30 was admitted to the facility on [DATE]. Review of Resident R30's Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/24/24, indicated the diagnoses of hemiparesis (one-sided muscle weakness), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and respiratory failure (a serious condition that makes it difficult to breathe on your own). Section C0500 the Brief Interview for Mental Status (BIMS)…

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

Based on facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for one of two residents reviewed (Resident R63). Findings include: Review of facility policy Colostomy/Ileostomy/Urostomy Care and Management dated 8/30/24, indicated to document the plan of care on the patient's electronic medical record including details such as: the size, shape, and color of stoma as well as the size and type of ostomy appliance being used. Review of Resident R63's clinical admission record indicated that resident was admitted to the facility 4/22/23, with diagnoses of high blood pressure, anxiety, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R63's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/11/24, indicated the diagnoses remain current. Review of Resident R63's physician orders dated 1/17/24, indicated to assist resident in…

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 records and facility policy review, and staff interview, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services for one of three residents (Resident R22). Findings include: Review of the facility policy Managing Behaviors dated 8/30/24, indicated when a behavioral concern emerges, an attempt to intervene as a team will be made. The plan should be documented. Document behaviors once the plan is initiated. Review of the Director of Social Services job description indicated it is the responsibility of the Director of Social Services to perform functions of a social worker including, being an interdisciplinary care plan team member, develop resident care plans, being a resident advocate, and educate residents, families and staff as it relates to psycho-social needs. Review of the clinical record indicated Resident R22 was admitted to the facility on [DATE]. Review of Resident R22's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records and staff interviews it was determined that the facility failed to ensure that a resident's drug regimen was free of unnecessary medication for one of two residents. (Resident R84) Findings include: Review of the facility policy Psychotropic Drugs dated 8/30/24, indicated a psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. The evaluation and documentation should address whether the psychotropic is still needed on a as needed basis, what the benefit of the medication is to the resident, and whether the resident's expressions or indications of distress have improved as a result of the medication. Review of the clinical record indicated Resident R84 was admitted to the facility on [DATE], with diagnoses of Parkinson's Disease (a movement disorder of the nervous system that worsens over time), depression, and intellectual disabilities. Review of Resident R84's Minimum Data Set (MDS - a periodic assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to limit as needed antipsychotic drugs to 14 days for two of four residents (Resident R84 and R122). Findings include: Review of the facility policy Psychotropic Drugs dated 8/30/24, indicated a psychotropic drug is any drug that affects brain activities associated with mental processes and behaviors, to include Anti-anxiety medications. All PRN (as needed) psychotropic medications will have a limitation of 14 days duration for orders. Review of the clinical record indicated Resident R84 was admitted to the facility on [DATE], with diagnoses of Parkinson's Disease (a movement disorder of the nervous system that worsens over time), depression, and intellectual disabilities. Review of Resident R84's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/2/24, indicated diagnoses were current. Review of a physician order dated 4/25/24, indicated to administer 0.5 mg tablet of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in one out of two medications rooms (Wellstep) and failed to properly store a medication on one of four medications carts (2nd Floor Middle Hall Medication Cart). Findings include: Review of the facility policy Storage of Medication dated [DATE], indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. During an observation on [DATE], at 1:27 p.m. of the 2nd Floor Middle Hall Medication Cart indicated the following medications were expired: - Resident R2's Victoza pen (prefilled pen used to help control blood sugar, insulin levels, and digestion) expired [DATE]. During an interview on [DATE], at 1:28 p.m. Licensed Practical Nurse (LPN) Employee E18 confirmed the above findings. During an observation on [DATE], at 1:31 p.m. of the Wellstep Medication Room indicated the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observations, and staff interviews it was determined that the facility failed to provide adaptive feeding devices for one of four residents (Resident R1). Findings include: Review of the facility policy Assistive Devices dated 8/30/24, indicated any assistive equipment/devices will be available to any resident for whom equipment would be beneficial in assisting the resident's ability to maintain or improve current function. Review of the admission record indicated Resident R1 admitted to the facility on [DATE], and readmitted [DATE]. Review Resident R1's active physician order dated 8/4/21, indicated the resident is to have a blue inner lip plate with meals. Review of Resident R1's MDS dated [DATE], indicated the diagnoses of encephalopathy (a disease that affects brain structure or function), aphasia (a disorder that affects language and communication), and epilepsy (a brain condition that causes recurring seizures.) During an observation on 10/8/24, at 12:12 p.m. Resident R1's lunch…

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

Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for two of ten months (September and October 2024). Findings include: Review of facility policy Infection Control Program dated 8/30/24, indicated review of designated microbiological reports; review antibiotic usage, antibiotic susceptibility/resistance, and trend studies. Review of the facility's Infection Control surveillance for January - October 2024, failed to include documentation to indicate that antibiotic monitoring was completed for two of ten months (September and October 2024). During an interview on 10/9/24, at 1:33 p.m. the Director of Nursing confirmed that the facility failed to implement an antibiotic stewardship program that included a system of surveillance to monitor antibiotic use and lab correlation for infections for two of ten months and was unable to produce the tracking records for September and October 2024. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code:…

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 documents and staff interview, it was determined that the facility failed to provide training on resident rights for one of five staff members (Employee E7). Findings include: Review of facility policy Staff Education dated 8/30/24, indicated that staff will complete yearly mandatory education requirements. Required education includes Resident Rights. Review of the facility provided staff list indicated that Nurse Aide (NA) Employee E7 was hired on 1/7/16. Review of NA Employee E7's facility provided training record did not include training on resident rights. During an interview on 10/10/24, at 9:02 p.m. Nursing Home Administrator confirmed that the facility failed to provide training on resident rights for one of five staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility documents, employee education records, and staff interview, it was determined that the facility failed to provide training on QAPI (Quality Assurance and Performance Improvement) for one of five staff members (Employee E7) Findings include: Review of facility policy staff education dated 8/30/24, indicated that staff will complete yearly mandatory education requirements. Required education includes QAPI. Review of the facility provided staff list indicated that Nurse Aide (NA) Employee E7 was hired on 1/7/16. Review of NA Employee E7's facility provided training record did not include training on QAPI. During an interview on 10/10/24, at 9:02 p.m. Nursing Home Administrator confirmed that the facility failed to provide training on QAPI for one of five staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records and staff interview, it was determined that the facility failed to update a care plan for one of nine residents (Resident R1) to accurately reflect the current status of the resident. Findings include: Review of clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included dementia (declining cognitive abilities of remembering, thinking, or making decisions), anxiety and major depressive disorder. Review of Resident R1's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 5/16/24, indicated the diagnoses remain current. Review of Resident R1's Resident Care Plan Summary Report (report nurse aides used to know what kind of care to provide) dated 7/1/24, indicated bed mobility as a assist of two. Review of Resident R1's care plan dated 9/6/23, indicated R1 had a bed mobility assist of one and that it was active, current. During an interview on 7/9/24, at 1:30 p.m. Nursing Home Administator…

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, incident reports, facility documents, a written employee statement and staff interviews, it was determined that the facility failed to ensure that a resident was free from a preventable accident during care for one of nine resident reviewed (Resident R1). Findings include: Review of clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included dementia (declining cognitive abilities of remembering, thinking, or making decisions), anxiety and major depressive disorder. Review of Resident R1's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 5/16/24, indicated the diagnoses remain current. Review of Resident R1's care plan dated 9/6/23, indicated R1 had a bed mobility assist of one. Review of facility documents dated 6/26/24, indicated Nurse Aide (NA Employee E1) was providing care. NA Employee E1 remained beside. Resident R1 starting rolling in the opposite direction, NA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to report an allegation of abuse in the required timeframe for four of four residents (Residents R3, R4, R5, and R6). Findings include: Review of facility policy Abuse, Prevention of Resident Abuse dated 08/30/24, indicated all incidents of actual, alleged, or suspected abuse, neglect, theft, misappropriation of resident property, or injury of unknown origin will be promptly reported and thoroughly investigated. All alleged/suspected violations and all substantiated incidents of abuse, neglect, theft, exploitation or misappropriation of resident property, will be promptly reported to all appropriate state licensing agencies and other entities or individuals as may be required by law. Review of Title 42 Code of Federal Regulations (CFR) 483.12(c) states in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must ensure that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, facility documentation, and staff interview, it was determined that the facility failed to fully investigate allegations of abuse for four of four residents (Residents R3, R4, R5, and R6). Findings include: Review of facility policy Abuse, Prevention of Resident Abuse dated 08/30/24, indicated all incidents of actual, alleged, or suspected abuse, neglect, theft, misappropriation of resident property, or injury of unknown origin will be promptly reported and thoroughly investigated. Review of Title 42 Code of Federal Regulations (CFR) 483.12 ( c ) indicated In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. 483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. 483.12(c)(4) Report the results of all investigations to the administrator or his or her designated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, facility documentation, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents were free from abuse for one of five residents (Resident R2) and failed to identify concerns as abuse for four of five residents (Residents R3, R4, R5, and R6). Finding include: Review of facility policy Abuse, Prevention of Resident Abuse dated 08/30/24, indicated all incidents of actual, alleged, or suspected abuse, neglect, theft, misappropriation of resident property, or injury of unknown origin will be promptly reported and thoroughly investigated. Review of Title 42 code of Federal Regulations (CFR) 483.12(a)(1) indicated Abuse, is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility documents and staff interview, it was determined that the facility failed to make certain a resident was free from a physical restraint for one of five residents reviewed (Resident R2). Findings include: Review of facility policy Physical and Chemical Restraints dated 8/30/24, indicated physical restraints are defined as any manual, physical, or mechanical device, material, or equipment attached to adjacent to the resident's body that he cannot remove easily which restricts freedom of movement or normal access to one's body. The use of any physical restraint should only be an intervention of last resort where there is an imminent risk of harm. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/15/24 indicated diagnoses of high blood pressure, hip fracture, and dementia (a group of symptoms that affects memory,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to implement the written policies and procedures to ensure a complete and thorough investigation and timely reporting was completed for four of four abuse allegations (Residents R3, R4, R5, and R6). Finding include: Review of facility policy Abuse, Prevention of Resident Abuse dated 08/30/24, indicated all incidents of actual, alleged, or suspected abuse, neglect, theft, misappropriation of resident property, or injury of unknown origin will be promptly reported and thoroughly investigated. All alleged/suspected violations and all substantiated incidents of abuse, neglect, theft, exploitation or misappropriation of resident property, will be promptly reported to all appropriate state licensing agencies and other entities or individuals as may be required by law. Review of Title 42 Code of Federal Regulations (CFR) 483.12(c) states in response to allegations of abuse, neglect, exploitation,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain that elopement evaluations are completed as required for one of seven residents (Resident R1), and that each resident received adequate supervision that resulted in an elopement for one of two residents (Resident R1). Findings include: Review of facility policy Elopement Risk Assessment last reviewed 8/30/23, indicated that residents will be assessed for elopement risk on admission, quarterly, and as needed with significant changes. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident 1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 6/12/24, indicated diagnoses of dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory), bradycardia (slow heart rate), and anxiety (a feeling of worry, nervousness, or unease). Review of Resident R1 ' s admission Nursing…

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

Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly label and date food products in the Main Kitchen (Main Kitchen) and failed to properly monitor refrigerator temperatures on one of two nursing unit pantries (Wellstep Path) which created the potential for food borne illness. Findings Include: Review of the facility policy Sanitation in Food Purchasing, Storage and Distribution last reviewed 8/30/23, indicated that all opened food items will be stored in properly covered and dated containers. Review of facility policy Food Brought into Residents' Room from Outside Sources last reviewed 8/30/23, indicated that nursing staff will monitor refrigeration units. All units must be maintained at internal temperatures that are deemed safe for food storage according to State and Federal regulations. During an observation in the Main Kitchen walk-in refrigerator, on 11/27/23, at 9:50 a.m., a metal bin that contained an open package of hot dogs did not have a label or date, and was not sealed, and a pie that was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, national and state guidance, clinical record review, observations, and staff interviews, it was determined the facility failed to identify a COVID positive resident, and implement the proper precautions before the spread to other persons in the facility for one of three residents (Resident R58); failed to implement measures to prevent the potential for cross contamination during removal of Personal Protective Equipment after a dressing change for one of two residents (Resident R84), and failed to provide a safe and sanity environment to help prevent the potential for cross contamination for one of two medication rooms (Third Floor Medication Room). Findings include: Review of Title 42 Code of Federal Regulations (CFR) §483.80 - Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain physician's orders, update resident care plans, and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for four of six residents (Residents R7, R15, R19, and R79). Findings include: Review of facility policy Side Rail Use last reviewed 8/30/23, indicated if side rails are determined to be appropriate, the nurse must obtain a physician's order for the use of quarter side rails. The use of enabler/assist bar or quarter side rails to enable independence with bed mobility must be care planned. The continued use of the enabler/assist bar or quarter side rails must be assessed on a quarterly basis by the nurse or with any change in resident's status that would affect the independent use of the enabler/assist bar or quarter side rail. Review of the clinical record indicated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of four residents (Resident R7). Findings include: Review of facility policy Medication Administration - General Guidelines last reviewed 8/30/23, indicated that residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with professional procedures for self-administration of medications. Review of the clinical record indicated that Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's Minimum Data Set (MDS - a period assessment of care needs) dated 11/14/23, indicated a Brief Interview for Mental Status (BIMS - a screening test that aides in detecting cognitive impairment) of 15 indicated Resident R7 is cognitively intact, and diagnoses of diabetes mellitus (high blood sugar), bipolar disorder (a mental condition marked by alternating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain privacy of confidential information during medication administration for one of three medication carts ([NAME] Medication Cart). Findings include: Review of facility policy Confidentiality last reviewed 8/30/23, indicated employees must be vigilant to make sure that confidential information, including resident financial and health records, are not inadvertently disclosed to individuals who do not have authorization or a need-to-know. Computer systems storing confidential information must be secure and destroyed when legal or regulatory methods for its retention no longer apply. During an observation on 11/30/23, at 9:28 a.m. the [NAME] Medication Cart was observed outside of resident room [ROOM NUMBER] with the computer screen open with resident information visible to anyone passing by in the hallway. A report sheet with resident information was also present on the medication cart and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility documents, and resident and staff interviews, it was determined that the facility failed to provide appropriate assistance to prevent falls as ordered, for two of three residents reviewed (Resident R5 and R56). Findings include: Review of the facility Abuse Prevention of Resident Abuse, Neglect, Mental Abuse, Reports of Theft, Exploitation and Misappropriation of Property policy dated 9/23, indicated it is the facility policy to provide a safe and secure environment for all residents and will protect a resident's right to be from any form of abuse and neglect. Review of the facility's Use of Mechanical Lift policy dated 8/30/23, indicated the facility must provide the safest lifting/transferring technique as determined by nursing or therapy to maintain the resident highest level of functioning. It was indicated transfer orders are to be confirmed by reviewing the Activities of Daily Living book or physician orders in the medical chart prior to use of mechanical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate injuries of unknown origin for one of four residents reviewed (Resident R2). Findings include: A review of the facility's Abuse, Neglect, and Exploitation policy dated 8/30/23, indicated an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. It states physical injury of a resident of unknown source is a possible indicator of abuse. It was indicated the facility must identify and interview all persons, including alleged victim, alleged perpetrator, witnesses and other who might have knowledge of the allegations. It was indicated complete and thorough documentation of the investigation must be provided. Review of the facility's Resident Incident or Accident Report policy dated 8/30/23, indicated all incidents and accidents involving a resident shall be documented on an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, closed resident records and staff interview, it was determined that the facility failed to acquire physician's discharge order for two out of three closed resident records (Closed Record CR73 and CR89). Finding include: The facility Discharge Summary Guidelines policy dated 8/30/23, indicated that the facility will provide discharge information on a resident to receiving organizations and subsequent health care providers. Review of Closed Record CR73's admission record indicated he was admitted [DATE], with diagnosis that included dementia (a group of symptoms that affects memory, thinking and interferes with daily life), high blood pressure, and depression. Review of Closed Record CR73's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/1/23, indicated that the diagnoses remain current upon review. Review of Closed Record CR73's clinical note dated 11/8/23, indicated that he will be discharged to his new apartment on 11/15/23. Review of an additional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for one of three residents reviewed (Resident R352). Findings include: Review of the facility policy Oxygen: Via Concentrator dated 6/2017, last reviewed on 8/30/23, indicated that oxygen concentrators are used to supply oxygen with liter flows on 1 to 10 liters per minute (LPM). It was indicated the oxygen tubing must be dated and attached to the green adapter or humidifier. Review of the facility policy Oral Inhalation and Nebulizer Administration dated 1/9/17, last reviewed on 8/30/23, indicated that it is the facility policy to allow for safe, accurate, and effective administration of medications using an oral inhaler or nebulizer (changes a medication into a mist so it can be inhaled into the lungs). Once a respiratory treatment is completed, the nebulizer must be turned off and disconnected. Review of admission record indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in one out of three medication carts ([NAME] Medication Cart), failed to monitor refrigerator temperatures utilized for medication storage in one of two nursing units (Wellstep Path), and failed to properly secure a medication cart while not in use for one of three medications carts ([NAME] Medication Cart). Findings include: A review of facility policy Medication Storage last reviewed 8/30/23, indicated that all medications dispensed by the pharmacy are stored in the container when the pharmacy label. Certain medications or package types such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, blood guar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiation date to insure medication purity and potency. Only licensed nurses, pharmacy personnel, and those lawfully authorized 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 a review of facility policy, resident clinical records, facility documents, and staff interview, it was determined the facility failed to obtain a physician order for hospice services for one of five residents (Resident R74) and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for two of five residents (Resident R51 and R74). Findings include: Review of the facility Skilled Nursing - Comprehensive Care plans dated 8/3023, indicated that the effectiveness of the care plan must be evaluated from its initiation and modified as necessary. This should be done with any significant change in condition. Communication about care plan changes should be ongoing among interdisciplinary team. Review of the facility policy Hospice Service, dated 8/30/23, indicated that the attending physician will be asked to determine if the patient has a six-month or less prognosis, which is part of the criteria for eligibility. Review of the clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record, and staff interview it was determined that the facility failed to notify families of residents with positive COVID-19 test results in a timely manner for one of three COVID-19 positive residents (Residents R58.) Findings include: Review of the facility's Notification of change in condition policy dated 8/30/23, indicated the resident representatives will be notified of a significant change in the resident's physical, mental, or psychosocial status. Review of the clinical record revealed that Resident R58 was admitted to the facility on [DATE]. Review of Resident R58 Minimum Data Set (MDS - periodic assessment of resident's care needs) dated 9/27/23, revealed diagnoses of Chronic obstructive pulmonary disease (COPD is a group of diseases that cause airflow blockage and breathing-related problems), high blood pressure, and heart failure (a progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath.)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly label and date food products, and verify the sanitizing temperature of the dish machine in the Main Kitchen (Main Kitchen), and properly monitor refrigerator temperatures, and properly store food products in one of three nursing unit pantries ([NAME]) and failed to properly date food and monitor food for expiration dates in three of three nursing unit pantries ([NAME], Wellstep, and Creekside), which created the potential for food borne illness. Findings Include: Review of the facility policy Food Storage: Sanitation and Infection Control last reviewed 3/23/23, indicated that all products are labeled and dated with the receiving date. Review of the facility policy Dishwashing and Pot Washing Procedures: Sanitation and Infection Control last reviewed 3/23/23, indicated that setting the right temperature for the commercial dishwasher is critical to ensure property sanitized cookware,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for four of 16 Residents (Resident R9, R35, R148 and R246). Findings include: Review of the facility policy Comprehensive Care Plan Completion dated 8/31/22, indicated the facility will develop a comprehensive plan of care for each resident, and that each triggered Care Assessment Area (CAA) must be assessed to facilitate care plan decision making. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 6/5/23, included diagnoses of schizoaffective disorder (a mental disorder in which a person experiences a combination of schizophrenia and mood disorder symptoms), bipolar disorder (a mental condition marked by alternating periods of elation and depression), and post-traumatic stress disorder (PTSD, mental health…

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, resident observations and interviews, clinical record review, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care for three of five residents (Residents R35, R148, and R152). Findings include: Review of the facility's policy Oxygen Via Concentrator dated 8/31/2022, indicated the facility will verify physician orders for oxygen therapy and that oxygen tubing will be changed every 2 weeks and as needed. Review of the clinical record indicated Resident R35 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 6/8/23, indicated diagnoses of pneumonia (severe inflammation of the lungs from an infection), bronchitis (inflammation of the lining of the tubes that carry air to and from the lungs), and respiratory failure (a serious condition where the lungs cannot get enough oxygen into the blood). Observation and interview of Resident R35 on 6/14/23, at 11:09 a.m.…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on abuse and neglect prevention for two of ten staff members (Employees E4 and E5). Findings include: Review of the Facility Assessment dated 9/28/22, indicated facility staff will complete annual mandatory training on abuse, neglect, misappropriation, and exploitation. The facility Abuse, Prevention of Abuse, Neglect, Mental Abuse, Reports of Theft, Exploitation and Misappropriation of Property policy dated 8/31/22, indicated all employees are required to participate in mandatory annual educations relative to resident rights and training relating to abuse. Review of Nurse Aide (NA) Employee E4's education record indicated she was hired on 1/7/16. Review of NA Employee E4's training record for 1/7/22, through 1/7/23, did not include training on abuse and neglect. Review of Registered Nurse (RN) Employee E5's education record indicated she was hired on 2/26/19. Review of RN Employee E5's training record for 2/26/22, through 2/26/23, did not 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.