Casselman Healthcare And Rehabilitation Center

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.

Based on a review of the facility's admissions agreement, as well as resident and staff interviews, it was determined that the facility failed to establish an admissions policy that did not request/require residents to waive potential facility liability for losses of personal property. Findings include: An undated admission agreement given to every new resident included the statement that the facility would not be responsible for the loss of the resident's personal property, such as money, documents, clothing, or other personal effects. The agreement did not describe the types of losses that the facility would be liable for. Interview with a group of residents on August 8, 2023, at 1:30 p.m. revealed that they were not offered a locked box for storing personal items or valuables until they had something stolen or missing. They indicated that they would have accepted a locked box to store valuables or money in their rooms if they were offered it on admission. Interview with the Director of Nursing on August 9, 2023, at 2:35 p.m. confirmed that the facility had residents sign 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 the Resident Assessment Instrument User's Manual and clinical records, the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set (MDS) validation report, as well as staff interviews, it was determined that the facility failed to ensure that the Care Area Assessment Process of comprehensive Minimum Data Set assessments and comprehensive assessments were completed in the required time frame for five of 89 residents reviewed (Residents 21, 30, 53, 62, 78). 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 2019, indicated that for admission MDS assessments, the assessment completion date, and the Care Area Assessment (CAA - the process of completing an in-depth assessment of triggered, potentially problematic care areas) completion date (Item V0200B2) were to be…

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 Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for nine of 89 residents reviewed (Residents 20, 35, 46, 56, 69, 74, 94, 96, 98). 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 2019, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to have a completion date (Section Z0500B) that was no later than the ARD plus 14 calendar days. A quarterly MDS assessment for Resident 20 had an ARD of May 19, 2023, but it was not completed (Section Z0500B) until June 4, 2023. 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 review of the Resident Assessment Instrument, clinical records, and the Minimum Data Set validation report, as well as staff interviews, it was determined that the facility failed to transmit Minimum Data Set (MDS) assessments to the required electronic system, the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within 14 days of completion for 53 of 89 residents reviewed (Residents 1, 2, 4, 5, 6, 7, 8, 10, 15, 16, 17, 21, 23, 24, 25, 26, 29, 34, 35, 38, 51, 52, 55, 57, 59, 60, 62, 63, 64, 65, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 98, 99, 100, 101). 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 (federally-mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that comprehensive MDS assessments must be transmitted electronically within 14 days of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for four of 89 residents reviewed (Residents 4, 17, 71, 74). Findings include: The Long-Term Care Facility 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 2019, revealed that Section O0100C (Oxygen therapy) was to be coded with the number of days the resident received supplemental oxygen during the seven-day assessment period. An Annual MDS for Resident 4, dated May 31, 2023, revealed that section O0100C was coded (yes), indicating that the resident did receive supplemental oxygen while a resident in the facility during the seven-day look-back assessment period. Review of the Medication Administration Record (MAR) for Resident 4, dated May, 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 clinical record reviews, as well as observations and resident and staff interviews, it was determined that the facility failed to develop individualized care plans that included the resident's individualized care needs for four of 89 residents reviewed (Residents 5, 46, 61, 67). 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 5, dated May 4, 2023, revealed that the resident was understood and able to understand others, required supervision for personal care needs, and had diagnoses that included dementia with agitation and major depressive 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 policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that physicians orders were followed for two of 89 residents reviewed (Residents 4, 125) Findings include: The facility's policy for Nursing Care of the Resident with Diabetes, dated July 31, 2023, indicated that for asymptomatic (no symptoms) responsive residents with hypoglycemia (blood sugar less than 70 milligrams per deciliter (mg/dl)) staff were to give the resident an oral form of rapidly absorbed glucose (sugar) and recheck the blood sugar in 15 minutes. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated June 4, 2023, revealed that the resident was understood and able to understand others, required extensive assistance from staff for daily care needs, and had diagnosis that included diabetes. A care plan for insulin dependent diabetes for Resident 4, dated July 19, 2022, indicated to obtain glucometer (device used to measure blood sugar) readings and report…

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 files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for three of three nurse aides reviewed (Nurse Aide 3, Nurse Aide 4, Nurse Aide 5). Findings include: Review of Nurse Aide 3' personnel file revealed that she was hired December 20, 2019. There was no evidence that Nurse Aide 3 had a performance evaluation completed since her hire date. Review of Nurse Aide 4's personnel file revealed that she was hired August 22, 1988. There was no evidence that Nurse Aide 4 had a performance evaluation completed since 2019. Review of Nurse Aide 5's personnel file revealed that she was hired December 18, 1989. There was no evidence that Nurse Aide 5 had a performance evaluation completed since 2019. Interview with the Nursing Home Administrator on August 9, 2023, at 12:30 p.m. confirmed that performance evaluations were not completed for any staff since 2019 and that they should be done annually. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code…

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

Based on review of facility 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 August 7, 2023, revealed that there was to be chicken Alfredo, buttered noodles, buttered chopped spinach, dinner roll, margarine and oatmeal raisin cookie served for lunch on August 7, 2023, and on Tuesday, August 8, 2023, there was to be lemon pepper fish, parslied white rice, seasoned asparagus cuts, dinner roll, margarine, chocolate brownie, and tartar sauce. Observations on Monday, August 7, 2023, revealed that the lunch meal consisted of turkey with gravy, mashed potatoes, spinach, and cake. There was no chicken Alfredo, buttered noodles, or cookie. Observations on Tuesday, August 8, 2023, revealed that the lunch meal consisted of a hamburger steak with gravy, white rice, asparagus…

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 provide the required notice to the resident or the resident's representative following the end of their Medicare coverage, or failed to provide 48-hour advanced notice, for one of three residents reviewed (Resident 90) and failed to provide the notice timely to one of three residents reviewed (Resident 125). Findings include: Resident 90's medical record revealed that he began Medicare A services on May 11, 2023, and his last covered day was May 25, 2023. The medical record indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. The facility had no documented evidence that the resident was issued a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form or an Advance Beneficiary Notice (ABN) as required. A SNF Beneficiary Protection Notification Review form, completed by the facility and dated February 10, 2023, revealed that Medicare coverage for Resident 125 started 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.

Based on observations and staff interviews, it was determined that the facility failed to ensure a homelike environment related to the storage of wheelchairs in the main dining room. Findings include: Observations on August 7, 2023, at 1:06 p.m. revealed that there were eight wheelchairs stored in the corner of the main dining room on the third floor around the piano and a table. Interview with Licensed Practical Nurse 1 on August 7, 2023, at 1:19 p.m. revealed that the wheelchairs are stored in the main dining room on the third floor because there is not enough room for them in the residents' rooms. Interview with the Director of Nursing on August 7, 2023, at 2:49 p.m. confirmed that the chairs should not be stored in the main dining room. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete a significant change Minimum Data Set assessment for one of 89 residents reviewed (Resident 14). Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs) revealed that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. The RAI Manual revealed that staff should complete a significant change MDS when a resident has a decline that will not normally resolve itself without interventions by staff, impacts more than one area of the resident's health status, and requires interdisciplinary review and/or revision of the resident's care…

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

Based on review of 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 89 residents reviewed (Resident 4). Findings include: A facility policy for Plans of care dated July 31, 2023, indicated that resident assessments are ongoing and care plans are revised as information about the resident and their condition changes. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated June 4, 2023, revealed that the resident was understood and able to understand others, required extensive assistance from staff for daily care needs, and had diagnoses that included encephalopathy (brain disease that alters the function of the brain) and diabetes. Physician's orders for Resident 4, dated July 13, 2023, included an order that the resident be fed all meals by nursing staff. A review of care plans for Resident 4, revised June 14, 2023, included 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 facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that assistance devices to prevent accidents or injury were in place as care planned for one of 89 residents reviewed (Residents 59), and that the facility failed to complete safety assessments for one of 89 residents reviewed (Resident 71) who used an air mattress. Findings include: The facility's policy regarding bed safety, dated July 31, 2023, indicated that the resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 59, dated June 29, 2023, revealed that the resident could make himself understood and could understand others, required supervision with personal care needs, and had…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that central venous catheters were flushed per facility policy for one of 89 residents reviewed (Resident 1). Findings include: The facility's policy regarding flushing central venous catheters (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications), dated July 31, 2023, indicated that the catheter was to be flushed before and after it was used to administer medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 3, 2023, revealed that the resident was cognitively impaired, needed extensive assistance for daily care needs, and had diagnoses that included urinary tract infection. Physician's orders for Resident 1, dated August 1, 2023, included and order for the resident's peripherally-inserted central catheter (PICC - a type of central venous catheter) to receive 500 milligrams (mg) of Meropenem (an antibiotic…

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 ensure that physician's orders for tracheostomy care (care of a surgical incision in the neck that creates an opening into the windpipe) included what size inner cannula (an inner tube inserted within the main outer cannula of the tracheostomy tube) to use for one of 89 residents reviewed (Resident 68). Findings include: The facility's policy for tracheostomy care, dated July 31, 2023, indicated that staff should check physicians' orders prior to providing tracheostomy care. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 68, dated July 19, 2023, revealed that the resident was cognitively intact, required extensive assistance with daily care needs, and had diagnoses that included cancer of the head, face and neck, and presence of a tracheostomy. Physician's orders for Resident 68, dated August 8, 2023, included that the resident receive tracheostomy care that included to…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for two of 89 residents reviewed (Residents 43, 67). Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 43, dated June 20, 2023, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included depression and PTSD. A review of Resident 43's care plan, dated February 20, 2020, indicated that the resident had PTSD and depression. There was no documented evidence the facility identified Resident 43's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring. Interview with 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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a physician performed the initial comprehensive visit with the resident for one of 89 residents reviewed (Resident 125). Findings include: Resident 125's clinical record revealed that the resident was admitted to the facility on [DATE], discharged to home on January 20, 2023, and again admitted to the facility on [DATE]. A Certified Registered Nurse Practitioner's (CRNP, a registered nurse who has advanced education and clinical training in a health care specialty area) note for Resident 125, dated January 11, 2023, revealed that the resident was seen by the CRNP. Additional CRNP notes, dated January 18, 2023; February 1, 2023; and February 10, 2023, revealed that all visits were completed by the CRNP and not the attending physician. A CRNP note, dated January 11, 2023, was signed by the physician; however, it stated that the resident was seen by the CRNP and would be seen later when 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 the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) surveys ending September 20, 2022, and Feburary 8, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending August 9, 2023, identified repeated deficiencies related to quality of care, safety/accidents, and homelike environment. The facility's plan of correction for a deficiency regarding a failure to ensure that the environment was homelike, cited during the survey ending on February 8, 2023, revealed 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.