Riverside Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure equipment was in safe operating condition for one of two crash carts (carts maintained with equipment used in emergencies) (700-Hall crash cart).Findings include: Review of the facility policy Emergency Equipment Check Policy dated 9/12/25, indicated, Emergency equipment/cart[s] will be checked daily and items which are outdated or opened will be replaced. During an observation on 1/6/26, at 2:30 p.m. of the Emergency Cart located in the 700-Hall medication room, the following was noted:(3) Yankauer with an expiration date of 2/28/24.(1) Dressing Change Kits with an expiration date of 3/20/25.(1) Central Line Dressing Change Kit with an expiration date of 1/31/24.(1) IV Start Kit with an expiration date of 6/30/25.(1) Luer Lock Y-Sites with an expiration date of 4/13/22.(1) Bottles of sterile normal saline with an expiration date of 9/1/25.(2) Bottles of sterile normal saline with 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.

Based on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Nurse Aide Employees E8 and E9).Findings include:Review of facility provided documents and training records revealed the following staff members did not have 12 hours of in-service education:NA Employee E8 had a hire date of 7/1/23, with 4.10 hours of in-service education between 7/1/24, and 7/1/25.NA Employee E9 had a hire date of 7/1/23, with 0.00 hours of in-service education between 7/1/24, and 7/1/25.During an interview on 1/8/26, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews with staff, it was determined that the facility did not ensure that a physician wrote, signed, and dated progress notes at each visit for one of two residents reviewed (Resident R1).Findings include:Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included Clostridium difficile (C. diff - highly contagious bacterium that causes diarrhea and colitis), diabetes, and high blood pressure. Resident R1 was on respite (provides short-term relief for primary caregivers, giving them time to rest, travel, or spend time with other family and friends) stay for seven days.Review of the clinical record indicated Resident R1 was seen by the wound doctor on 10/13/25, with the following orders:Wound #1 Left, Plantar Foot: Cleanse Wound. Cleanse with 0.125% Dakin's Solution - and pat dry. Pack undermining, areas and wound bed with kling, cutting only once and leaving tail end visible out of wound bed. Cover with ABD and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to develop a baseline care plan that included dialysis care and interventions needed to provide effective and person-centered care for three of seven residents (Resident R1, R2, and R3).Based on review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to develop a baseline care plan that included dialysis care and interventions needed to provide effective and person-centered care for three of seven residents (Resident R1, R2, and R3). Findings include: The facility policy Interim/Baseline-Care Plans reviewed 1/13/25, indicated a baseline care plan to meet the resident's immediate needs shall be developed within forty-eight hours of the resident's admission. Review of the admission record indicated Resident R1 was originally admitted to the facility on [DATE], with the diagnosis of chronic kidney disease, stage 4 (severe kidney damage requiring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to make certain consistent dialysis communication was maintained for three of six residents (Residents R1, R3, and R4).Findings include: Review of the facility policy Hemodialysis Care Policy dated 1/13/25, indicates pre -dialysis process includes document assessment in the dialysis communication tool. Post-dialysis process includes receive report from dialysis provider and/or review dialysis communication tool documentation by dialysis provider.Review of the admission record indicated Resident R1 was originally admitted to the facility on [DATE].Review of Resident R1's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 8/8/25, diagnosis of chronic kidney disease, stage 4 (severe kidney damage requiring dialysis), hypertension, and heart failure. Review of Resident R1's physician orders dated 8/15/25, indicated dialysis: at [Dialysis Center], Monday, Wednesday, and Friday.…

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 observations and staff interviews, it was determined that the facility failed to ensure the dish machine was in proper working order in the Main Kitchen. Findings include: During an observation on 7/8/25, of the noon meal, it was noted that all the residents received their meals in Styrofoam containers and cups. During an observation on 7/8/25, of the Main Kitchen it was noted that the drainage sink of the dishwasher had standing water in it. During an interview on 7/8/25, at 1:10 p.m. Dietary Employee E1 confirmed that the dishwasher had been inoperable since Saturday morning (7/5/25), and that on Saturday and Sunday (7/5/25, 7/6/25), dietary employees had been washing dishes by hand. During an interview on 7/8/25, at 1:12 p.m. Dietary Manager confirmed she was not aware that the dishwasher was inoperable until the morning of 7/7/25, and she directed staff to use Styrofoam containers and cups. At this time, Dietary Manager Employee E2 confirmed that the facility administration was aware of the dishwasher was not working. Dietary Manager Employee E2 confirmed…

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 during care for and an injury of unknown origin possible neglect for three of four residents (Resident R1, R2, and R3). Findings include: Review of facility policy Abuse, Neglect and Exploitation dated 1/2/24, indicated it is that facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/10/25, included diagnoses of atrial fibrillation and dementia. Review of Section C: Cognitive Patterns indicated Resident R1 had severe cognitive impairment. Review of Section GG: Functional Abilities indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of observations and resident and staff interviews it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for three of five of residents (R4, R5, and R6). The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 5/13/25, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls for two of four residents (Resident R1 and R2). Review of the facility policy, Fall Management dated 1/2/24, indicated if risks are identifed, preventative measures will be put in place and care planned. All falls will be reviewed and investigated. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 4/10/25, included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns indicated Resident R1 had severe cognitive impairment. Review of Section GG: Functional Abilities indicated Resident R1 utilized a walker and a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident representative of changes in condition for one of four residents (Resident R1). Findings include: Review of the facility, Resident Change in Condition Policy dated 1/2/24, indicated The physician/provider and resident/family/responsible party will be notified when there has been an accident or incident involving the resident. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/10/25, included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns indicated Resident R1 had severe cognitive impairment. Review of an incident report dated 6/14/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and staff interviews, it was determined that the facility failed to implement a physician ordered follow-up MRI Scan for one of three residents reviewed with brain cancer (Resident R1). Findings include: Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses which included a Glioblastoma removal with a craniotomy from a traumatic brain injury. Resident R1 had developed behaviors s/p the craniotomy and required constant monitoring, he was placed on the MIU(Memory care unit) of the facility as the resident also been exit seeking. Review of the clinical record indicated that on 4/30/25, Resident R1 had been sent to the hospital due to increased unsteadiness on his feet and a change in condition. Review of the clinical record indicated that on 5/7/25, Resident R1 returned to the facility with and order for a MRI on May 9, 2025. Resident R1's wife gave the paperwork and information to Licensed Practical Nurse (LPN) Employee E1.…

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 Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for six of 24 residents (Resident R67, R147, R148, R153, R248, and R249). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that an admission MDS assessment was to be completed no later than 14 days following admission. Resident R67 had an admission date of 12/4/24, with an MDS completion date of 1/8/25. Resident R147 had an admission date of 12/2/24, with an MDS completion date of 1/11/25. Resident R148 had an admission date of 12/20/24, with an MDS not completed as of 1/13/25. Resident R153 had an admission date of 11/29/24, with an MDS completion date of 1/5/25. Resident R248 had 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.

Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that that quarterly Minimum Data Set (MDS- periodic review of resident care needs) assessments were completed within the required time frame for three of eight residents reviewed (Resident R44, R52, and R76). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required MDS assessments, dated October 2023, indicated that quarterly MDS assessments were to be completed no later than 14 days after the Assessment Reference Date (ARD). Resident R44 had an ARD of 12/5/24, with an MDS completion date of 1/7/25. Resident R52 had an ARD of 12/18/24, with the MDS not completed as of 1/13/25. Resident R76 had an ARD of 12/5/24, with an MDS completion date of 1/7/25. During an interview on 1/8/24, at 1:35 p.m. the Registered Nurse Assessment Coordinator (RNAC) Employee E9 confirmed that the facility failed to make certain 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 records, and staff interview, it was determined that the facility failed to revise/update care plans for two of eight residents to accurately reflect the current status of the resident (Residents R5 and R195). Findings include: Review of facility Comprehensive Care Planning Policy dated 1/13/25, previously reviewed 1/2/24, indicated that in cases of significant changes in the resident's condition, the care plan must be updated within seven days of the new MDS. Review of the admission record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/4/24, indicated the diagnoses of Alzheimer ' s disease (a type of brain disorder that causes problems with memory, thinking and behavior), anemia (too little iron in the body causing fatigue), and chronic kidney disease (gradual loss of kidney function). Review of Resident R5's physician order dated 6/11/24, indicated to that…

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

Based on a review of facility documentation, cited deficiencies from previous surveys, review of plan of correction documentation, and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. This has the potential to affect 26 of 84 residents. Finding include: Review of the facility policy Quality Assurance and Performance Improvement (QAPI) Program Policy dated 1/13/2025, indicated objectives of the QAPI program include providing a means to establish and implement performance improvement projects to correct identified negative or problematic indicators and to establish systems through which to monitor and evaluate corrective actions involving all levels of the organization. The facility's deficiencies and plan of correction for the State Survey and Certification (Department of Health) survey ending 1/5/24, revealed the facility developed a plan of correction that included quality assurance systems to ensure the facility maintained compliance with cited nursing home…

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 record, facility policy, and staff interview, it was determined that the facility failed to develop a baseline care plan that included diabetes care and interventions needed to provide effective and person-centered care for four of fourteen residents (Resident R22, R32, R44, R150, and R195) . Finding include: The facility policy Baseline-Care Plans reviewed 1/2/24, indicated a baseline care plan to meet the resident's immediate needs shall be developed within forty-eight hours of the resident's admission. Review of the admission record indicated Resident R22 was admitted to the facility on [DATE], with the diagnosis of diabetes mellitus (too much sugar in the blood). Review of Resident R22's baseline care plan completed on 1/11/25, indicated the resident has not been care planned for diabetes. Review of the admission record indicated Resident R32 was admitted to the facility on [DATE], with the diagnosis of diabetes mellitus. Review of Resident R32's baseline care plan completed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of Resident Assessment Instrument (RAI) User's Manual, 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 five of fourteen residents (R22, R32, R44, R150, R195). Finding include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions or completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated the following instructions for Section V Care Area Assessment (CAA) Summary, Questions V0200: For each triggered Care Area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. The Care Planning Decision column must be completed within 7 days of completing the RAI (MDS and CAA(s)). Check column B if the triggered care area is addressed in the care plan. Review…

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

Based on policy review, documentation and review of Centers for Disease Control (CDC) guidelines for Legionella (bacteria that causes disease found in contaminated water) control, and staff interviews it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for ten of twelve months (April 2024 through January 2025). Finding include: Review of the facility policy Legionella Assessment and Prevention Program dated 1/13/25, previously dated 1/2/24, indicated the facility will utilize water management practices to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Core Elements of the Water Management Plan are: 1. Establish Water Management Plan team. 2. Describe Center's water system using text and flow diagram. 3. Risk assessment with control methods and corrective actions. 4. Monitoring control measures. 5. Corrective actions. 6. Verification and…

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

Based on review of facility policy, facility documents, clinical records, and staff interview, it was determined that the facility failed to identify and investigate incidents of possible neglect and abuse for two of three residents (Residents R1 and R2). Findings include: Review of the facility policy Abuse/ Neglect, last reviewed on 1/2/24, with a previous review date of 4/21/23, indicated that it is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, exploitation, etc. Facility staff must immediately report all such allegations to the Administrator. The Administrator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy. Review of the facility Event Summary Report, dated from 1/1/24 through 3/31/24, indicated Resident R1 had a fall while receiving care when Resident R1 rolled out of bed with no injuries identified on 2/21/24. Review of the incident report dated 2/21/24, indicated Resident R1 kept rolling during incontinence care and slid onto the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to make certain significant medications are administered as ordered by the physician for one of four residents (Resident R3). Findings include: A review of the facility policy Medication Administration last reviewed on 1/2/24, with a previous review date of 4/21/23, indicated to administer medications as prescribed by the provider. A review of the clinical record indicated that Resident R3 was admitted to the facility on [DATE], with diagnoses that included syncope, muscle weakness and rheumatoid arthritis (the body's immune system attacks its own tissue, mainly in the hands and feet). A review of the MDS(Minimum Data Set - periodic assessment of resident care needs) dated 2/15/2024, indicated the diagnoses remain current. A review of a physician order dated 2/14/2024, indicated to give Hydroxychloroquine (immunosuppressive) oral tablet 200 mg (milligrams) one tablet by mouth every twelve…

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 documents, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 16 of 25 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, and R16). Findings Include: Review of the Facility Assessment dated 1/2/24, indicated the facility will provide necessary person-centered care and services. During an observation on 2/17/24, at 12:13 p.m., Resident R1 had unkempt, greasy appearing hair. Resident R1 was eating lunch, still wearing a gown. During an interview and observation on 2/17/24, at 12:16 p.m., when asked if there were enough nursing staff to care for the residents, Resident R2 stated that she had no concerns. Observation at this time revealed Resident R2 to be still wearing a gown while eating lunch, slumped to her left side, leaning against her enabler bar. Resident R2's meal cover was still on her food,…

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 and clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for eight of eight residents reviewed (Resident R5, R6, R44, R57, R65, R70, R76, R188). Findings include: A review of the facility Advance Directives Protocol reviewed January 2023 and 1/2/24, indicated upon admission advance directives will be discussed with the resident and/or resident representative to determine is any advance directives have been chosen. Advance directives will be reviewed at minimum annually according to MDS (Minimum Data Set - mandated assessments of a resident's abilities and care needs) schedule. A review of the medical record indicated Resident R5 was re-admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (gradual and progressive brain disorder…

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, resident and staff interviews, it was determined the facility failed to make certain residents were notified of the procedure for filing a grievance, failed to have grievance boxes and forms labeled for resident use on one of three nursing units (200/300/400 hall), and failed to make certain the current grievance official's name and contact information was posted. Findings include: Review of the facility policy Resident Grievances and Concerns Policy reviewed January 2023 and 1/2/24, indicated the facility recognizes that residents have the right to voice grievances without discrimination or reprisal. The facility will make available to all residents via posting in a prominent location in the facility contact information for the grievance official. During a resident group interview conducted on 1/4/24, at 1:00 p.m., seven residents were asked if they knew how to file a grievance or a concern and how they would file anonymously, five of seven residents were unclear on how to file a grievance, and they did not know who the current grievance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for five of seven Residents (Residents R6, R44, R57, R65, and R236). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding 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 review of facility policy, clinical records and staff interviews, it was determined that facility staff failed to maintain ongoing communication with the dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for two of three residents reviewed (Resident R57, and R239). Findings include: Review of the facility policy Hemodialysis Care Policy last reviewed on January 2023 and 1/2/24, indicated communication between the hemodialysis provider and facility staff will occur before and after each hemodialysis treatment and as needed. Post-dialysis information will include: vital signs, post-treatment weight, lab draws and/or results, medications administered during or after treatment, any new orders, and any additional alerts or information. A review of the clinical record indicated that Resident R57 was re-admitted to the facility on [DATE], with diagnoses that included end stage kidney disease (the kidneys…

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, observation, resident and staff interview, it was determined that the facility failed to respect residents' rights in the handling and protection of their personal property and clothing for one of three residents reviewed. (Residents R188). Findings include: Review of the facility policy Resident Rights and Facility Responsibilities reviewed January 2023 and 1/2/24, indicated it is the facility's policy to comply with all Resident Rights, and to communicate these rights to residents. The Nursing Home Reform Act established the following rights for nursing home residents: -The right to freedom from abuse, mistreatment, and neglect; -The right to freedom from physical restraints; -The right to privacy; -The right to accommodation of medical, physical, psychological, and social needs; -The right to participate in resident and family groups; -The right to be treated with dignity; -The right to exercise self-determination; -The right to communicate freely; -The right 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 the facility's abuse prohibition policy, clinical records and staff interviews it was determined that the facility failed to ensure that one of three residents reviewed was free from misappropriation (Resident R188) Findings included: Review of the facility policy Pennsylvania Resident Abuse reviewed January 2023 and 1/2/24, indicated the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Misappropriation is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings or money without the resident's consent. The facility will contact the police for any allegation of misappropriation of resident property. Review of the facility policy Personal Belongings Policy reviewed January 2023 and 1/2/24, indicated the facility will ensure each resident has the right to retain and to use personal possessions while residing in facility. Staff will inventory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive care plan to meet care needs for two of 24 residents (Residents R10 and R12). Findings include: Review of facility policy Comprehensive Care Planning dated January 2023, indicated an interdisciplinary care plan will be established for every resident and updated in accordance with state and federal regulatory requirements. Review of facility policy Psychotropic Gradual Dose Reduction dated January 2023, indicated once the inter-disciplinary team has completed the Psychopharmacologic Review Form, a plan of care will be developed to include specific non-pharmacological interventions. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of the MDS (Minimum Data Set-Resident Assessment and Care Screening) dated 8/3/23, indicated diagnoses of dementia and heart failure. A review of Section O, Special Treatments,…

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 and clinical record review and resident and staff interviews, it was determined that the facility failed to make certain that showers were consistently provided for two of six residents (Resident R31, and R65). Findings include: Review of the facility Resident Bath/Showering/Scheduling Policy dated January 2023, indicated each resident will be asked about their bathing preference and will be scheduled to receive bathing a minimum of two times per week unless they prefer less frequent baths. The facility will maintain a bathing/showering schedule for each unit. Review of Resident R31's admission record indicated that Resident R31 was admitted to the facility on [DATE], with diagnoses that included neurocognitive disorder (decreased mental function and loss of ability to do daily tasks), diabetes, and obesity. Review of Resident R31's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 8/22/23, indicated that diagnoses remain…

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, facility provided documents and staff interview it was determined the facility failed to report an incident of an elopement to the State Survey Agency within five working days for one of four residents (Resident R1). Findings include: Review of facility policy titled Incident/Accident Policy last reviewed on 6/21/22, informed an incident/accident is any occurrence which is not consistent with the routine care of a particular resident. Any required regulatory reporting will be completed. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizophrenia (a chronic brain disorder to include delusions, hallucinations, disorganized speech and lack of motivation), diabetes, intellectual disabilities (a problem with mental ability that affects learning, problem solving, judgement, communication, and independent living), and pressure ulcers of the right and left heels. Review of Resident R1's Minimum Data Set (MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, resident clinical records, and staff interviews, it was determined the facility failed develop and implement a base line care plan within 48 hours of the resident's admission that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. Findings include: Review of facility policy titled Comprehensive Care Planning last reviewed 6/21/22, informed an interim care plan must be developed within 48 hours of admission to ensure that the resident's needs are met appropriately until the comprehensive care plan is completed. A comprehensive care plan must be developed by the Interdisciplinary Care Planning Team within seven days after the completion of the comprehensive assessment (Minimum Data Set (MDS) - a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes that helps to identify a resident's functional capabilities and 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 policy, facility provided documents, resident clinical record, alarm contractor documentation, staff interviews, and staff witness statements, it was determined the facility failed to provide a safe environment and adequate supervision to an elopement risk resident, and to maintain mechanical and electrical equipment in a safe operating condition creating the opportunity for the elopement of a one of four residents (Resident R1). Findings include: Review of facility policy titled Elopement/Unauthorized Absence Policy last reviewed 6/21/22, informed the facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. All residents will be assessed for the risk of elopement using the [NAME] Elopement Assesment on admission, quarterly, and as…

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

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to obtain and document a physician's discharge order for four of five residents discharged (Residents R1, R2, R3, and R4). Finding include: Review of the facility Discharge/Transfer Documentation Check List Guide for Nursing and Social Services policy dated 7/1/23, indicated transfers to the ER/ED (emergency room/emergency department) must include an order to transfer, and for routine discharges to home, another facility or assisted living, a discharge order is obtained from the physician. Discharges must be documented in the progress notes. Review of Resident R1's face sheet indicated an admission date of 6/23/23, with diagnoses that included dementia and heart disease. Review of Resident R1's Discharge Summary indicated the resident was discharged to another facility on 7/19/23. Review of Resident R1's clinical record did not include a physician order, or a progress note to discharge from the facility on 7/19/23. Review of Resident R2's face sheet indicated 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.