Casselman Healthcare And Rehabilitation Center

Review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to revise/update care plans after an incident for one of 5 residents reviewed (Resident 2). Findings include: The facility's policy regarding care plans, dated April 7, 2025, indicated that the care plan will be reviewed and revised to reflect changes in the resident's status. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 21, 2025, indicated that the resident was cognitively intact, could understand and was understood, required assistance from staff for her daily care needs and had diagnoses that included, morbid obesity, anxiety and chronic migraines. A care plan, revised July 14, 2025, indicated that Resident 1 had the potential to be verbally aggressive related to ineffective coping skills. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 3, 2025, indicated that 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 Pennsylvania's Nursing Practice Act and information submitted from the facility, it was determined that the facility failed to ensure that a licensed practical nurse's license remained current for one of one licensed practical nurse's reviewed (Licensed Practical Nurse 2). This was cited as past non-compliance.Findings include:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, for the expiration and renewal of licensure revealed that notice of the renewal period of a license will be sent to each active licensee prior to the expiration date of the licensee's license. The applicant for license renewal may complete and submit an application online or may mail a completed application form to the Board's administrative office. When applying for licensure renewal, a registered nurse shall complete and submit the renewal application, including disclosing any license to practice nursing or any allied health profession in any other state, territory,…

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 and residents' clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 28 residents reviewed (Residents 3, 38, 52). Findings include:The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, revealed that Section N0415F1 (antibiotic medication) was to be checked if the resident received an antibiotic medication during the seven-day assessment period and Section N0415K1 was to be checked if the resident received an anticonvulsant medication during the seven-day assessment period.Physician's orders for Resident 3 dated May 1, 2025, included an order for the resident to receive 300 milligrams (mg) of Gabapentin two times a day for diabetic neuropathy (nerve damage that can cause pain, numbness, tingling, and weakness in the hands and feet, and sometimes other parts of…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 28 residents reviewed (Residents 4 and 9). A facility policy for Care Plan Revisions Upon Status Change dated April 7, 2025, indicated that the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 4 dated May 2, 2025, indicated that the resident was cognitively intact, required assistance with daily care needs, and had diagnoses that included Multiple Sclerosis (disease in which the immune system eats away at the protective covering of nerves). The Care plan for Resident 4 dated October 13, 2023, indicated that the resident was receiving diuretic therapy (water pills, to increase urine production and help the body eliminate excess fluid and sodium). Review of the Medication…

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 policy and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders related to bowel protocols for one of 28 residents reviewed (Resident 42).Findings include:A facility policy for Bowel Movements Monitoring dated April 7, 2025, indicated that all residents' bowel movements will be documented. If a resident has not had a bowel movement for three full days, the licensed nurse will follow bowel protocol as ordered by the physician. All shifts will then monitor for effectiveness. If initial laxative is ineffective, then a second laxative if ordered is given as per order. Resident will be monitored on all shifts for bowel movements to see if second laxative was effective. If the second laxative was ineffective, then an enema will be given per physician order. All three shifts will monitor resident for bowel movement to see if enema was effective. If enema is ineffective, notify the physician.A quarterly MDS assessment for Resident 42 dated July 3, 2025, indicated that the resident was cognitively…

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 job descriptions and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that staff renewed their nurse aide registry to allow individuals to work as a nurse aide for one of three nurse aides reviewed (Nurse Aide 3). Findings include:The facility's job description, undated, revealed that a nurse aide certification was necessary to perform functions of the position. This was cited as past-noncompliance.The personnel file for agency Nurse Aide 3 revealed that her certification on the nurse aide registry expired on [DATE]. The facility was unaware that Nurse Aide 3's certification on the nurse aide registry had expired until they were notified on [DATE], by Nurse Aide 3. Nurse Aide 3 worked in the facility from [DATE] through [DATE] and was immediately removed from the schedule when it was discovered that her registry had expired. Interview with the Director of Human Resources on [DATE] at 11:06 a.m. confirmed that Nurse Aide 3'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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled for one of 28 residents reviewed (Resident 37). Findings include:The facility's policy regarding labeling of medications, dated April 7, 2025, indicated that all medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Labels for individual drug containers must include appropriate instructions and precautions. The pharmacy must be informed of any changes or changes in directions for use of the medication. Physician's orders for Resident 37, dated July 1, 2025, indicated that the resident was to receive two 300 milligram (mg) capsules of Gabapentin (a medication used to treat nerve pain) daily and one 300 mg capsule of Gabapentin at bedtime. Observations during the medication administration on July 31, 2025, at 8:24 a.m. revealed that Licensed Practical…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of 28 residents reviewed (Resident 3).Findings include:The facility's policy regarding laboratory services and reporting, dated April 7, 2025, revealed that the facility would provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The facility would provide or obtain laboratory services to meet the needs of its residents.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 25, 2025, revealed that the resident was cognitively intact and had diagnoses that included hypothyroidism (when the thyroid gland doesn't make and release enough hormone into your bloodstream). A pharmacy review for Resident 3, dated May 3, 2025 revealed the resident was taking levothyroxine (medication used to treat hypothyroidism) 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, clinical records and facility investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from misappropriation of medications for one of five residents reviewed (Resident 3).Findings include:The facility's policy regarding controlled narcotics dated April 7, 2025, indicated that the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the comprehensive drug abuse prevention and control act of 1976). Misappropriation was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent example drug diversion (taking the residents medication).A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 29, 2025, revealed that the resident was cognitively intact, required assistance…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for one of three residents reviewed (Resident 1).Findings include:The facility's policy regarding medication administration, dated April 7, 2025, indicated that the individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones.The facility's policy regarding controlled substance administration, dated April 7, 2025, states that an individual controlled substance record is made for each resident who will be receiving a controlled substance.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 14, 2025, revealed that the resident is cognitively intact, required assistance for daily care needs, and had medical diagnosis that 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.

Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bells were within reach for two of six residents reviewed (Residents 3, 5). Findings include: The facility's policy for call lights: accessibility and timely response, dated May 31, 2024, indicated that the purpose was to ensure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility, to allow residents to call for assistance. Staff would ensure the call light was within reach of residents and secured, as needed. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 3, dated March 21, 2025, revealed that the resident could usually make herself understood and understand others, had moderate cognitive impairment, required assistance from staff for care needs, was occasionally incontinent of bladder, and had diagnoses that included seizures. A care plan for Resident 3, dated February 16, 2024,…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide care for pressure ulcers in accordance with professional standards of practice, by failing to ensure that recommendations from a wound consultant were reviewed with the attending physician for one of six residents reviewed (Resident 2) who had pressure ulcers. Findings include: The facility's policy regarding the prevention of pressure ulcers, dated May 31, 2024, indicated that the facility would review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. The resident was to be assessed on admission for existing pressure injury risk factors, repeated weekly, and upon any changes in condition. The facility was to select appropriate support surfaces and pressure redistribution based on the resident's risk factors, in accordance with current clinical practice. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities…

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 and staff interviews, it was determined that the facility failed to maintain a clean, homelike environment in the second floor ice room and in resident rooms for one of eight residents reviewed (Resident 1). Findings include: Observations in the second floor ice room on January 29, 2025, at 9:09 a.m. revealed that there was an ice machine sitting on a wooden type bench/platform. The platform was greenish/blue in color with a moderate amount of chipped paint. The front and top of the platform was noted to have a blackish-brown, removable substance on it that measured approximately 10.0 x 15.0 inches. Interview with the Maintenance Director on January 29, 2025, at 12:17 p.m. confirmed that in the past the ice machine leaked and dripped water onto the top of the platform, which over time resulted in the blackish, removable substance. Observations in Residents 1's room on January 29, 2025, at 9:13 a.m. revealed that there were four holes in the dry wall to the left of the resident's television measuring approximately 5.0 x 4.0 inches each. Interview with Resident 1…

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, staff interviews, and manufacturer's instructions, it was determined that the facility failed to ensure that battery packs were replaced in mechanical lifts. Findings include: Manufacturer's directions for the ArjoHuntleigh Lifter Battery Pack SPL3021, dated August 9, 2016, used for the facility mechanical lifts (equipment used to safely and easily move residents) revealed that the battery life is variable (2-5 years) and depends on proper charging practices. Batteries were to be recharged on a regular basis (at least monthly), they were not to reach a low charge state, and the battery packs were to be removed from the lift when not used for a long period of time. Interviews with Nurse Aide 1 and Nurse Aide 2 on January 29, 2025, at 10:10 a.m. indicated that even when the mechanical lift batteries are fully charged, they are losing their charge very quickly, which makes it difficult and frustrating to provide timely and safe care to the residents. Observations of the five battery chargers in the second floor dining and linen rooms on January 29, 2025, at 12:30…

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 reviews and staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one one of six residents reviewed (Resident 5). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated October 4, 2024, revealed that the resident was understood; could understand others; had diagnoses that included anemia (low blood count), heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the body's organs), hypertension (high blood pressure), diabetes, cerebral vascular accident (CVA - commonly known as a stroke), and chronic obstructive pulmonary disease (COPD -a common lung disease that makes it difficult to breathe); and received oxygen therapy. A nursing note for Resident 5, dated November 2, 2024, at 2:00 a.m., and completed by Licensed Practical Nurse 1, revealed that at approximately 2:00 a.m. the writer went down to the second floor to change 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 review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart. Findings include: The facility's policy regarding medication labeling and storage, dated May 31, 2024, indicated that compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Observations on August 13, 2024, at 8:58 a.m. revealed that Licensed Practical Nurse 1 left a medication cart out of sight, unattended and unlocked in the hallway when she entered a resident's room. An interview with Licensed Practical Nurse 1 at the time of the observation confirmed that her medication cart was not locked when she entered a resident's room, and it should have been. Interview with the Nursing Home Administrator on August 13, 2024, at 9:17 a.m. confirmed that the medication cart should have…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for one of 31 residents reviewed (Resident 26) who were receiving hospice services. Findings include: The facility's Hospice Program policy, dated May 31, 2024, indicated that in general, it was the facility's responsibility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided was appropiately based on the individual resident's need, which included communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident were addressed and met 24 hours per day. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 26, dated July 24, 2024, indicated that the resident was cognitively intact, received hospice services, and had a…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative in writing of the transfer and reason for hospitalization for one of 31 residents reviewed (Resident 54). Findings include: A nursing note for Resident 54, dated May 20, 2024, revealed that the resident was admitted to the facility that afternoon. A nursing note for Resident 54, dated May 25, 2024, revealed that the writer received a call from the resident's son at 7:28 p.m. that the resident was not answering her cell phone. The resident's son stated that he felt that the resident has had a decline over the last few days. The writer relayed information to the resident's son that she received in report about the resident's increased weakness and orthostatic blood pressures (a condition where blood pressure drops suddenly when someone stands up from a sitting or lying position). The writer assured the resident's son that she would go back and assess the resident, update him, and make sure the resident's phone was charged and within…

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 policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that physicians orders were followed for one of 31 residents reviewed (Resident 21). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 21, dated June 25, 2024, revealed that the resident was understood and able to understand others, was cognitively impaired, required substantial assistance from staff for daily care needs, and had diagnoses that included heart failure and hypertension (high blood pressure). A care plan for for Resident 21, dated August 5, 2024, indicated that the resident had an actual fall due to poor balance and an unsteady gait. A nursing note for Resident 21, dated August 4, 2024, at 1:31 a.m., revealed that resident was found sitting on his buttocks on the floor in his room. The resident was incontinent of bowel at the time of the fall. A nursing note for Resident 21, dated August 4, 2024, at 9:40 p.m., revealed that he had a witnessed fall.…

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 policies, as well observations and staff interviews, it was determined that the facility failed to maintain an environment free of potential safety hazards related to the facility's hot water temperatures. Findings include: A facility policy for safe water temperatures, dated January 31, 2024, included that water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 degrees Fahrenheit (F), or the maximum allowable temperature per state regulation. Observations of the Maintenance Director checking water temperatures in sinks on the second and third floors on June 21, 2024, between 9:52 a.m. and 10:09 a.m. revealed temperatures from 114 degrees F to 125 degrees F. Interview with the Maintenance Director on June 21, 2024, at 10:18 a.m. revealed that the water temperature in the sinks in the residents' rooms should be no higher than 110 degrees F, and that he could adjust the water temperatures as needed. Interview with the Nursing Home Administrator on June 21, 2024, at 11:42 p.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 a review of facility policy, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for three of four residents reviewed (Residents 2, 3, 4). Findings include: A facility policy for medication administration, dated January 31, 2024, revealed that after the medication has been administered, the nurse will initial the resident's Medication Administration Record (MAR) on the appropriate line and will record the date and time. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 7, 2024, revealed that the resident was cognitively intact, required assistance with care needs, was receiving hospice services, and received opioid (controlled drug used to treat pain) medication. Physician's orders for Resident 2, dated February 28, 2024, included an order for the resident to receive 50 milligrams (mg) of tramadol (controlled drug used to treat pain) every four hours 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 and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for four of seven residents reviewed (Residents 1, 2, 4, 6). Findings include: A facility policy regarding plans of care, dated January 31, 2024, indicated that resident assessments are ongoing and care plans are revised as information about the resident and their condition changes. The facility's policy regarding behaviors, dated January 31, 2024, indicated that interventions and approaches would be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan would include, as a minimum, a description of behavioral symptoms, targeted and individualized interventions for the behavioral and/or psychosocial symptoms, the rationale for the interventions and approaches, specific and measurable goals for targeted…

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 policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of seven residents reviewed (Resident 4). Findings include: The facility's policy for abuse, dated January 31, 2024, indicated that residents had the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 23, 2024, indicated that the resident was usually understood and could usually understand others, was cognitively intact, had no behaviors, and had diagnoses that included anxiety…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to administer medications timely for a wound infection for one of six residents reviewed (Resident 1) and failed to follow treatment recommendations for one of six residents reviewed (Resident 1). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 17, 2023, indicated that the resident was usually understood and could usually understand others, was dependent on staff for personal hygiene needs, had a pressure ulcer (skin breakdown caused by prolonged, unrelieved pressure) and surgical wound, and had diagnoses that included osteomyelitis (infection in the bone) of the vertebra (spinal column), sacral (base of the spine) and sacrococcygeal (sacrum and tailbone) region. A skin and wound note for Resident 1, dated August 28, 2023, at 1:05 p.m. revealed that the resident was seen by the wound consultant who recommended an extended course of 100 milligrams (mg) of…

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

Based on review of facility policy and written menus, observations, and staff interviews, it was determined that the facility failed to follow their planned menu. Findings include: The facility's policy for menus, dated July 31, 2023, revealed that menus are served as written unless changed in response to preference, unavailability of an item, or a special meal. The written menu for the week of October 29, 2023, revealed that there was to be beef ravioli, marinara sauce, Italian parmesan vegetable medley, garlic french bread, and pineapple upside down cake for lunch. A plain beef ravioli recipe, dated October 11, 2023, indicated that six beef ravioli was a standard portion. Observations on Wednesday, November 1, 2023, revealed that the lunch meal consisted of cheese ravioli, marinara sauce, Italian parmesan vegetable medley, garlic french bread, and pineapple upside down cake. The posted menu outside of the dining hall indicated that the lunch meal was to be beef ravioli. Interview with the Dietary Manager on November 1, 2023, at 2:48 p.m., revealed that she was not working during…

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, clinical record reviews, as well as observations, and staff interviews, it was determined that the facility failed to develop individualized care plans that included the resident's individualized care needs for two of 20 residents reviewed (Residents 4, 13). Findings include: A facility policy for Comprehensive Person-Centered Care Plans, dated July 31, 2023, included that the interdisciplinary team, in conjunction with the resident and his or her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive person-centered care plan is developed within seven days of the completion of the required comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). A quarterly MDS assessment for Resident 4, dated August 25, 2023, revealed that the resident was able to make herself understood and understood others, was dependent on staff for personal care needs, and was always incontinent of bowel and bladder. A documentation report, dated…

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

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 20 residents reviewed (Resident 17). Findings include: A facility policy for Plans of care dated July 31, 2023, included that assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 17, dated September 9, 2023, indicated that the resident could make herself understood and could understand others, required extensive assistance with personal care needs, and had diagnoses that included end-stage renal disease. A care plan for Resident 17, dated August 7, 2023, revealed that the resident was at risk for falls and was to have a fall mat on the right side of her bed. Observations of Resident 17 on November 2, 2023, at 10:30 a.m. revealed that 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 review of policies, clinical records, and the facility's investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained as free from accident hazards as possible and failed to develop and implement interventions to prevent falls for one of 20 residents reviewed (Resident 6) who had a history of falling. Findings include: The facility's policy for managing falls and fall risk, dated July 31, 2023, indicated that staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with…

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 reviews and staff interviews, it was determined that the facility failed to ensure that weekly weights were obtained as recommended by the dietician for one of 20 residents reviewed (Resident 4) who had a weight loss. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated August 25, 2023, revealed that the resident was able to make herself understood and could understand others, was dependent on staff for personal care needs, and had diagnoses that included adult failure to thrive. A care plan for Resident 4, dated July 11,2023, indicated that the resident had the actual weight loss related to recommended mechanical and therapeutic diet. A care plan approach, dated July 27, 2023, revealed that the resident was to receive weights as necessary. A dietician note for Resident 4, dated August 7, 2023, revealed that she had unplanned weight loss with a plan to provide weekly weights to monitor more closely. A dietician note for Resident 4, dated September 14, 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.