Fox Subacute At Mechanicsburg

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for three of 14 residents reviewed (Residents 9, 14, and 17). Findings include: Review of facility policy, titled Medication Administration, with a last review date of December 31, 2024, revealed Medications are given at the time ordered or within 60 minutes before or after the time for bid [twice a day], tid [three times a day], or qid [four times a day] passes. Review of Resident 9's clinical record revealed diagnoses that included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), chronic respiratory failure (long term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body), tracheostomy (an opening or incision in the windpipe to relieve an obstruction to breathing), and dependence on a ventilator (a machine 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.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections, consistent with physician orders and the resident's person-centered care plan, for one of five residents reviewed for catheter care (Resident 37). Findings include: Review of facility policy, titled Catheter- Indwelling, last revised November 30, 2021, read, in part, Purpose: To maintain constant urinary drainage, facilitate bladder irrigation, and monitor renal function and contain urinary drainage in seriously ill residents while maintaining a closed system. Criteria: must be documented for strict (foley- catheter) output if ordered by the physician. Review of Resident 37's clinical record revealed diagnoses that included obstructive uropathy (when urine can't flow normally through your urinary tract due to a blockage), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free of unnecessary medications for one of one resident reviewed for antibiotic use (Resident 9). Findings include: Review of facility policy, titled Medication Regimen Review and Reporting, with a last review date of December 31, 2024, indicated that a Medication Regimen Review (MRR) is a thorough evaluation of the drug regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication and the consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. Review of Resident 9's clinical record revealed diagnoses that included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), chronic respiratory failure (long term condition in which the respiratory system is…

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

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident was free of unnecessary psychotropic medications for one of five residents reviewed for unnecessary medications (Resident 26). Findings include: Review of Resident 26's clinical record on January 7, 2025, revealed diagnoses that included hypertension (elevated/high blood pressure) and bipolar disorder (mental health disorder that causes extreme shifts in mood from depression to manic hyperactivity). Review of Resident 26's physician orders revealed orders for clonazepam (schedule IV controlled medication in the drug class of benzodiazepine) 3 milligrams (mg - metric unit of measure) every 24 hours as needed for restlessness for 14 days, with a start date of December 30, 2024, and end date of January 13, 2024. Review of Resident 26's clinical record revealed the as needed clonazepam had been continuously reordered every 14 days over the course of the prior year and beyond. Resident 26 also had a separate, standing order for clonazepam 1 mg two times a day for…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure residents were afforded the right to secure and confidential personal and medical records for one of 14 residents reviewed (Resident 18). Findings include: Review of Resident 18's clinical record revealed diagnoses that included quadriplegia (paralysis of both arms and both legs) and tracheostomy status (artificial opening to the trachea [aka windpipe] through which a machine provides breathing assistance). During observations on January 7, 2025, it was observed, from the hallway, that a paper was taped to the wall outside Resident 18's room to the left of the room number sign. It was observed that written on the paper was Resident 18's first name and clinical assessment findings, along with other statements. Written on the paper was the date of January 4, 202[5]. During a staff interview on January 8, 2025, at approximately 1:20 PM, Nursing Home Administrator (NHA) revealed that the paper contained notes written to communicate information for Resident 18'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.

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to notify the listed emergency contact person (Resident's Representative) of a critical lab value for one of three residents reviewed (Resident 1). Findings Include: Review of facility policy, titled Notification of Change in Status, updated November 30, 2018, revealed Purpose: To notify patient and/or family of any change in treatments or status, and to allow patient and/or family the opportunity to be involved in treatment or care if they so desire. Procedure: .B. Non-life threatening situation or a change in care due to a minor process i.e. pneumonia, change in treatment or medication, test results. Documentation: B. Non-life threatening situation: 1. The nurse taking off or receiving new information will discuss the change(s) with the patient and/or family member and document the discussion. Review of Resident 1's clinical record revealed diagnoses that included anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin,…

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

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one of three residents reviewed (Resident 1). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body) and atrial fibrillation (Afib - an irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident 1's physician note dated August 8, 2024, revealed that the physician assessed Resident 1 for an episode of hematuria (blood in the urine). Further review of the physician note revealed I told nurses we will hold blood thinners for 2 days and will check CBC [complete blood count lab work], BMP [basic metabolic panel blood test] and magnesium [a blood test to measure the amount of magnesium in the…

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

Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to ensure that residents were protected from the potential for abuse by failing to preform criminal history background checks prior to hire for one of five personnel files reviewed (Employee 14); and failed to verify the standing of professional licenses and/or nurse aide registry enrollment prior to hire for five of five personnel files reviewed (Director of Nursing [DON] and Employees 13, 14, 15, and 16). Findings include: Review of facility policy, titled Abuse Reporting, with an update of November 28, 2018, revealed, .criminal history background checks shall be performed on all newly hired employees seeking employment and monthly thereafter. In addition, the Nurse Aid Registry and appropriate state licensing boards shall be contacted for verification of status of every applicant seeking licensed position . Review of the Director of Nursing's (DON) personnel file revealed their nursing license verification was completed February 2, 2024, which was after her date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for four of 15 residents reviewed (Residents 10, 12, 18, and 50). Findings include: Review of Resident 10's clinical record on February 20, 2024, at 12:14 PM, revealed diagnoses that included pressure ulcer of right buttock stage four (wound that extends deep into tissues including muscle, tendons, and ligaments) and chronic respiratory failure (lungs ineffectively exchange carbon dioxide and oxygen). Review of Resident 10's quarterly minimum data sets (MDS -mandated assessment tool utilized to identify a resident's physical, mental, and psychosocial needs), with dates of March 29, 2023; August 7, 2023; and November 30, 2023, revealed section I1700 was coded no for MDRO (multi drug resistant organism). During a staff interview on February 22, 2024, at 11:29 AM, with Employee 2 (Infection prevention nurse) it was revealed Resident 10 has…

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, and staff interviews, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of one residents reviewed for diapysis services (Resident 18). Findings Include: Review of facility policy, titled Hemodialysis, with a last revision date of November 30, 2018, and a last review date of December 27, 2023, indicated under section titled Documentation that 1. The dialysis unit doing the dialysis will supply copy of their completed record for the patient chart; and 3. All patient observations, interventions, etc. will be recorded in the patient record. Review of Resident 18's clinical record revealed diagnoses that included end stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis) and bipolar disorder (a lifelong mood disorder and mental health condition that causes intense shifts in mood, energy levels, thinking patterns, and behaviors). Review of Resident 18's physician orders revealed the following orders: Dialysis…

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

Based on review of select facility personnel documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for three of five nurse aides reviewed (Employees 9, 10, and 11) and failed to ensure that in-service education was provided based on the outcome of these reviews for five of five nurse aides reviewed (Employees 8, 9, 10, 11, and 12). Findings Include: Review of personnel information revealed Employee 8's hire date was November 28, 2014, and that they had an annual performance review completed on May 22, 2023, but failed to reveal that in-service education was provided based on the outcome of this review. Review of personnel information revealed Employee 9's hire date was July 8, 2022; Employee 10's hire date was November 24, 2020; and Employee 11's hire date was August 15, 2021. Further review of personnel information for Employees 9, 10, and 11, failed to reveal that annual performance reviews were completed and that in-service education was provided based on the outcome of…

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

Based on facility policy review, product manufacturer label, observations, and clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (17 errors in 32 observations, 53.13%). Findings include: Review of the clinical record for Resident 7 revealed the resident has a gastric tube (tube inserted through the abdomen that delivers nutrition directly to the stomach). Review of Resident 7's current physician orders revealed medication orders for the following medications: Valium (medication for seizures) 5 mg, Metoclopramide (medication to treat stomach) 10 mg, Lamotrigine (medication for seizures) 25 mg, Lamotrigine 200 mg, Lasix (diuretic medication) 40 mg, Baclofen (medication for muscle spasms) 10mg, and Metoprolol (blood pressure medicine) 25mg. Observation on February 21, 2024, at 8:56 AM, revealed Employee 1 (Licensed Practical Nurse [LPN]) was observed administering the above listed medications to Resident 7. Employee 1 crushed all of the above listed medications together and administered…

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 reviews, observations, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen, receiving area, and three of three nourishment areas. Findings include: Review of facility policy, titled Storage- Food, not dated, read, in part, Food should be stored in a manner which maximizes food quality and safety. Review of facility policy, titled Labeling and Dating of Food, not dated, read, in part, Condiments in pantry areas will be discarded and replaced monthly. Any foods found that are not labeled and dated need to be discarded immediately. Observation of the dish machine in the main kitchen on February 20, 2024, at 9:49 AM, revealed the sanitizing final rinse cycle reached a maximum temperature of 178 degrees Fahrenheit (F). Review of the dish machine temperature log for February 2024, revealed all sanitizing final rinse temperatures recorded in the month of February were below the minimum temperature for food service safety of 180…

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 personnel training records and staff interview, it was determined that the facility failed to ensure each nurse aide was provided with the required in-service training consisting of no less than 12 hours per year for five of five nurse aide employee records reviewed (Employees 8, 9, 10, 11 and 12); failed to provide annual training that included dementia management and resident abuse prevention for four of five nurse aide employee records reviewed (Employees 8, 9, 10, and 11); and failed to provide annual training that included dementia management for one of five nurse aide employee records reviewed (Employee 12). Findings Include: Review of personnel information revealed Employee 8's hire date was November 28, 2014; Employee 9's hire date was July 8, 2022; Employee 10's hire date was November 24, 2020; Employee 11's hire date was August 15, 2021; and Employee 12's hire date was March 28, 2019. Review of facility training records failed to reveal that the aforementioned Employees completed 12 hours of required annual training in the past 12 months. Further 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 clinical record review, policy review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 15 residents reviewed (Residents 18 and 20). Findings include: Review of facility policy, titled Care Plan and Conference, last revised November 30, 2018, revealed, in part, Purpose: To facilitate communication of all disciplines of pertinent patient information to formulate a useful care plan that will drive patient care and improve outcomes .The care plan process will be monitored by all disciplines as necessary based on the resident's assessment of problems and needs. Review of Resident 18's clinical record revealed diagnoses that included bipolar disorder (a lifelong mood disorder and mental health condition that causes intense shifts in mood, energy levels, thinking patterns, and behaviors) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 18's physician orders revealed an order for Venlafaxine Hydrochloride oral…

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

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain adequate personal grooming of residents dependent on staff for assistance with these activities of daily living (ADLs) for two of 15 residents reviewed (Residents 31 and 37). Findings Include: Review of facility policy, titled Quality of Life, dated November 28, 2018, revealed 1. The facility will promote, maintain and enhance each resident's dignity and respect his or her individuality. a. Grooming residents as they wish to be groomed. Review of Resident 31's clinical record revealed diagnoses that included acute and chronic respiratory failure, paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within seven days), and chronic kidney disease stage 4 (kidneys are moderately or severely damaged and are not working as well as they should to filter waste from the blood). Review of Resident 31's current care plan revealed an intervention with a revision date of October 13, 2023,…

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

Based on observation, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 12). Finding include: Review of facility policy, titled wound care and pressure ulcer care, with an update date of November 30, 2018, failed to reveal guidance for hand hygiene during wound care. Review of facility policy, titled hand hygiene, with a revision date of November 30, 2022, revealed procedure section B read, in part, hand hygiene is performed using hand washing or ABHR (alcohol based hand rub) before and after the following scenarios: before and after direct contact with residents, before performing any non-surgical invasive procedures, before handling clean or soiled dressing, gauze pads, etc., after removing gloves or an entire set of PPE (personal protective equipment), before performing 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 observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of two residents reviewed (Resident 84). Findings include: Review of Resident 84's clinical record revealed diagnoses that included cerebral infarction (a stroke-damage to the brain from interruption of its blood supply), anoxic brain damage (injury to the brain that occurs when the oxygen supply to the brain is compromised or interrupted), and muscle weakness. Review of Resident 84's physician orders revealed an order for Resident to wear bilateral resting hand splints during the day to prevent contracture of wrist and fingers. Approach: Bilateral resting hand splints to be worn four hours a day, three times a week. Off for self-care, ROM (range of motion), skin checks, monitor for skin breakdown, dated January 31, 2024. Observation of Resident 84 on February 20, 2024, at 10:38 AM, revealed that they had both of their hands closed 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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring for acceptable parameters of nutritional status for one of 15 residents reviewed (Resident 20). Findings include: Review of facility policy, titled Weights, last revised November 30, 2020, revealed, in part, Notify Medical Provider, RNAC (Registered Nurse Assessment Coordinator), and Registered Dietitian within 24 hours, if the re-weight verifies a significant weight change for the resident. The Registered Dietitian will update/revise the resident's Care Plan to reflect the significant weight change, goals, and approached. Review of Resident 20's clinical record revealed diagnoses that included protein calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets), dysphagia (difficulty swallowing), and type 2 diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). Review of Resident 20's care plan revealed a…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to follow physician orders for residents receiving tube feedings for one of seven residents reviewed for tube feedings (Resident 31). Findings Include: Review of Resident 31's clinical record revealed diagnoses that included acute and chronic respiratory failure, paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within seven days), and chronic kidney disease stage 4 (kidneys are moderately or severely damaged and are not working as well as they should to filter waste from the blood). Review of Resident 31's current physician orders revealed an order dated October 27, 2023, for enteral feed (also known as tube feeding, is a way of sending nutrition right to the stomach or small intestine), Nepro at 50 mL/hour with free water flush of 40 mL every hour. Observation of Resident 31's feeding tube on February 20, 2024, at 11:29 AM, and February 21, 2024, at 9:49 AM, revealed Resident 31's feeding pump was set to give…

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

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure each resident was evaluated appropriately for the use of side rails for one of three residents reviewed for side rails(Resident 31). Findings Include: Review of Resident 31's clinical record revealed diagnoses that included acute and chronic respiratory failure, paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within seven days), and chronic kidney disease stage 4 (kidneys are moderately or severely damaged and are not working as well as they should to filter waste from the blood). Observation on February 20, 2024, at 11:32 AM, revealed Resident 31 in bed, with bilateral side rails attached to the top of the bed. Review of Resident 31's physician orders revealed an order dated October 30, 2023, for 1/4 side rails to assist with bed mobility and repositioning. Further review revealed that order was discontinued on February 16, 2024, and a new order was placed on February 16, 2024, for 1/4 rails for…

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

Based on observation, clinical record review, facility policy review, and staff interview, it was determined that the facility failed to maintain infection control practices to prevent the spread of infection for one of 13 residents reviewed (Resident 12). Findings include: Review of facility policy, titled wound care and pressure ulcer care, with an update date of November 30, 2018, revealed section titled procedure B 4, Discard the dressing and gloves in the waterproof red trash bag. Review of Resident 12's clinical record revealed diagnoses that included pressure ulcer of other site, unstageable (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) and candidiasis (fungal infection caused by a yeast). Review of Resident 12's current physician orders revealed a treatment order dated February 12, 2024, to cleanse the left lateral foot with normal sterile saline (NSS), apply medihoney (ointment with anti-inflammatory effects) to the wound bed, and cover with foam adhesive dressing daily and as needed (PRN) and lifetime…

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 regulations, facility policy review, and staff interviews, it was determined that the facility failed to have an Infection Preventionist (IP) that worked at least part time at the facility. Findings Include: The Centers for Medicare and Medicaid Services regulation §483.80(b)(3) states, The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility ' s IPCP. The IP must: Work at least part-time at the facility. The IP must physically work onsite in the facility. He/she cannot be an off-site consultant or perform the IP work at a separate location such as a corporate office or affiliated short term acute care facility. Review of facility policy, titled Infection Preventionist, with a review date of November 30, 2023, revealed The IP works at least part-time at the facility. During an interview with the Nursing Home Administrator (NHA) on February 21, 2024, at 11:41 AM, he stated that the prior IP left the role in December 2023 and Employee 2 has been the designated IP since then. He further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review, it was determined that the facility failed to ensure accurate clinical record documentation for one of three residents reviewed (Resident 1). Findings include: A review of the facility policy, titled Verbal Orders, Physician Orders and Diagnostic/Lab Reports, last revised November 30, 2018, revealed, a physician's verbal order received in person or by telephone, the nurse will document the complete order on the physician's order sheet or in PCC (electronic health record) then verify the order by reading it back to the physician. A review of the clinical record for Resident 1 on December 13, 2023, revealed clinical diagnoses that included ventilator associated pneumonia ([NAME]-lung infection) and quadriplegia (paralysis of all four limbs). Further review of the clinical record revealed that Resident 1 is currently in the hospital with an active diagnosis of [NAME]. A review of the clinical record for Resident 1 failed to reveal any…

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 investigation, facility policy review, clinical record review, and staff interviews, it was determined that the facility displayed past noncompliance in that they had failed to ensure staff report violations involving neglect of a resident for one of three resident records reviewed (Resident 1). Findings include: Review of facility policy, titled Abuse Reporting, last reviewed January 23, 2023, revealed the policy statement was, The facility shall protect its residents to the fullest extent possible from physical[,] verbal, sexual or mental abuse, acts of neglect, corporal punishment, involuntary seclusion and misappropriation of residents' property. As all residents have the right to be free from abuse, mistreatment, neglect or misappropriation of property. All individuals not adhering to said policy shall jeopardize their position with the facility. Review of the policies definitions section revealed the policy defined neglect as, .failure to provide oneself or the failure of a…

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