Oak Hill Center For Rehabilitation And Nursing

Based on clinical record review and staff interviews, it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident for one of three residents reviewed (Resident 1).Findings Include:Review of Resident 1's clinical record revealed diagnoses that included type II diabetes mellitus (condition characterized by high blood sugar levels due to insulin resistance and relative lack of insulin production) and muscle weakness (muscles aren't as strong as they should be).Review of Resident 1's June 2025 MAR (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Ozempic subcutaneous solution (medication that mimics a hormone that lowers blood sugar) every Sunday for diabetes mellitus.Further review of the MAR revealed that nursing staff documented 9 other/see note on Sunday June 22, 2025, and Sunday June 29, 2025. Review of Resident 1's progress notes failed to reveal further documentation for the aforementioned dates. Further review…

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

Based on clinical record review, facility dietary manual review, observations, and staff interviews, it was determined that the facility failed to provide a meal that was designed to meet the needs of residents requiring a mechanical soft meal, and failed to provide a pureed meal for one of three residents reviewed (Resident 1). Findings include: Review of the facility's dietary manual, section titled, Menus, revealed the facility's policy stated, .Menus are implemented by the Dietary Manager in conjunction with the Dietician . Further, review of subsection titled, Mechanical Soft Diet, stated, Purpose: The mechanical diet is modified in consistency to reduce the amount of chewing required to consume food. Review of the planned menu for April 22, 2025, lunch meal, revealed the mechanical soft lunch was to include ground chicken enchilada casserole and ground black beans. Review of the recipe for the chicken enchilada casserole revealed it included the instructions of, Mechanical Soft Steps: Remove desired number of servings to chop for the mechanical soft diets. Use a knife/fork or…

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

Based on resident and staff interviews, clinical record review, and document review, it was determined that the facility failed to ensure each resident is included and provided the right to participate in the person-centered care planning process for two of 32 residents reviewed (Residents 25 and 31). Findings Include: Review of the facility's New admission Introduction & Handbook, provided to each resident and/or his representative at admission read, in part, Care plans are created for each resident on admission, reviewed quarterly . You should expect to be invited to participate in Care Plan Meetings routinely. A review of Resident 25's physician's orders revealed diagnoses that included muscle weakness and chronic kidney disease (a long-term condition that occurs when the kidneys are damaged and can't filter blood properly). An interview with Resident 25, on November 18, 2024, at 11:02 AM, revealed he did not recall being invited to his recent quarterly care plan meeting. A review of Resident 25's clinical record failed to reveal any documentation of the Resident's recent…

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 document review, clinical record review, and staff interview, it was determined that the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF-ABN) form to two of three residents to inform those residents of items and services no longer deemed eligible for coverage under Medicare A (Residents 2 and 108). Findings Include: A review of Resident 2's clinical record revealed the last covered day of Medicare A services dated September 1, 2024. Review of the facility's provided notice, revealed the facility did not offer the Resident the SNF-ABN form as Resident 2 was planning to remain in the skilled nursing facility and receive skilled services. A review of Resident 108's clinical record revealed the last covered day of Medicare A services dated August 9, 2024. Review of the facility's provided notice, revealed the facility did not offer the Resident the SNF-ABN form as Resident 108 planned to remain in the skilled nursing facility and receive skilled services. An interview with the Nursing Home Administrator on November 19,…

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

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for four of 32 residents reviewed (Residents 33, 37, 46 and 67). Findings include: Review of Resident 33's clinical record revealed diagnoses that included Parkinson's Disease (long-term movement disorder where the brain cells that control movement start to die and cause changes in how one moves, feels, and acts) and moderate protein-calorie malnutrition (insufficient protein intake or protein deficiency). Review of Resident 33's recorded weights revealed that she weighed 100.8 pounds on February 13, 2024, and 89.4 pounds on August 18, 2024, which represented a significant weight loss of 11.31% in this approximately six month period. Review of Resident 33's August 24, 2024, 5 day MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed that a weight of 89 pounds was recorded on this assessment. Further…

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

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for two of three residents reviewed for pressure ulcers (Resident 64 and 84). Findings include: Review of facility policy, titled Wound Care, last reviewed September 25, 2024, read, in part, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing, Verify that there is a physician's order for this procedure. The policy also states to wash and dry your hands thoroughly prior to the start of the procedure, after removing the soiled dressing, and at the end of the procedure. [NAME] tape with initials, time, date and apply to dressing. Review of Resident 64's clinical record revealed diagnoses that included unspecified severe protein calorie malnutrition (an imbalance between the nutrients your body needs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for two of five residents reviewed for mobility (Residents 37 and 55). Findings Include: Review of facility policy, titled Restorative Nursing Services, last reviewed September 25, 2024, read, in part, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies). Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. Review of Resident 37's clinical record revealed diagnoses that included contracture of left hand (a permanent tightening of the muscles,…

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

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding, including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers, for two of three residents reviewed for tube feeding (Resident 53 and 67). Findings include: Review of facility policy, titled Enteral Nutrition, last reviewed September 25, 2024, read, in part, Adequate nutrition support through enteral nutrition will be provided to residents as ordered. Review of Resident 53's clinical record revealed diagnoses of hemiplegia and hemiparesis following cerebral infraction (weakness or the inability to move one side of the body due to blocked or reduced blood flow to the brain) and dysphagia (difficulty swallowing). Review of Resident 53's physician orders revealed an order for bolus feeding via gastrostomy tube (G-tube - a small flexible tube that is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to complete a timely assessment for trauma and then develop and implement an individualized person-centered care plan to render trauma-informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for two of 32 residents reviewed (Residents 10 and 105). Findings include: Review of facility policy, titled Trauma-Informed Care, last revised September 25, 2024, read, in part, Policy Statement .Care will be provided in a manner that prevent re-traumatization and promotes healing and empowerment. Procedures 2. Resident Assessment and Care Planning: Incorporate trauma screening into resident assessments to identify potential trauma histories. Develop individualized care plans that account for trauma-related needs, preferences, and triggers. Review of Resident 10's clinical record revealed diagnoses that included Post Traumatic Stress Disorder (PTSD - a disorder in which…

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

Based on observations, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to assess residents utilizing enabler bars/side rails for risk of entrapment, review the risks and benefits of the use of enabler bars/side rails with residents or their representatives, and obtain informed consent for enablers bars/side rails prior to use for two of three residents reviewed for use of enablers (Residents 84 and 105). Findings Include: A review of facility policy, Proper Use of Side Rails, undated, revealed, An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails .The use of side rails as an assistive device will be addressed in the resident care plan .Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. A review of Resident 84's physician's orders revealed diagnoses that included paraplegia (paraplegia is the loss of muscle function in the lower half of the body, including both legs, and morbid…

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

Based on observation, policy review, and resident and staff interviews, it was determined that the facility failed to ensure that prescription medications and treatments were stored in locked compartments and only accessible by authorized personnel for three of 32 residents reviewed (Residents 2, 80, and 84). Findings Include: A review of facility policy, Self-Administration of Medications, revised December 2016, revealed, Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration. A review of Resident 2's clinical record revealed diagnoses that included pain and rash. An observation in Resident 2's room on November 18, 2024, at 10:42 AM, revealed a medication cup with a powder substance at the Resident's bedside. When an inquiry was made, Resident 2 stated staff leave the powder there in order to have it available for use for the rash under her breasts. An interview with the Assistant Director of Nursing (Employee 3), at 10:45 AM, revealed the powder is used during resident care and should not be stored at…

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

Based on observation, policy review, and staff interviews, it was determined that the facility failed to ensure enhanced barrier precautions were implemented appropriately to maintain a safe and sanitary environment that supports infection prevention and control for one of 20 residents on enhanced barrier precautions (Resident 102) and residents not on enhanced barrier precautions (Residents 41 and 66). Findings include: Review of the facility policy. titled Enhanced Barrier Precautions (EBP). effective April 1, 2024, stated, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. Observation during tour 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 observations, policy review, clinical record review, and staff interviews, it was determined that the facility failed to conduct regular inspections of side rails/enabler bars to identify areas of possible entrapment for two of three residents reviewed for side rails/enabler bars (Residents 43 and 105). Findings include: A review of facility policy, Proper Use of Side Rails, undated, revealed, When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used). A review of Resident 43's clinical record revealed diagnoses that included abnormalities of gait (the manner of a person's walking) and mobility (the ability to move freely) and hypertension (elevated blood pressure). An observation of Resident 43's bed, on November 18, 2024, at 10:59 AM, revealed bilateral enabler bars attached to the Resident's bed. An interview with the Nursing Home Administrator (NHA) on November 21, 2024, at 9:51 AM, revealed 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 observation, state regulation, resident and staff interviews, record review, policy review, and the facility's licensed staff scope of practice, it was determined that the facility failed to follow professional standards of practice when providing medication administration for 2 of 32 residents reviewed (Residents 31 and 84). Findings include: Review of the Pennsylvania Nursing Practice Act for Licensed Practical Nurses (LPN), Chapter 21.145. revealed Functions of the LPN. (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. (1) An LPN shall communicate with a licensed professional nurse and patient's healthcare team members to seek guidance when the patient's care needs exceed the licensed practical nursing scope of practice. A review of the facility's policy, titled Administering Medications, revised…

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

Based on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for one of two residents reviewed for respiratory care (Resident 22). Findings include: Review of facility policy, titled Oxygen Administration, last reviewed September 2024, read, in part, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of Resident 22's clinical record revealed diagnoses that included bipolar disorder (a serious mental illness that causes extreme mood shifts, including periods of mania and depression) and hypertension (high blood pressure). Observation of Resident 22 on November 18, 2024, at 10:38 AM, revealed the Resident was sitting in their room, using oxygen running at 4 liters per minute. Observation of Resident 22 on November 20, 2024, at 12:23 PM, revealed the Resident was sitting in their room, using oxygen running at 4 liters per minute.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards, and failed to maintain complete and accurate records related to dialysis communication for one of one resident reviewed for dialysis (Resident 326). Findings include: Review of facility policy, titled Hemodialysis Access Care, last reviewed September 2024, read, in part, Do not use the access site arm to take blood pressure. Review of Resident 326's clinical record revealed diagnoses that included ESRD (End Stage Renal Disease - failure of kidney function to remove toxins from blood), hypertension (elevated/high blood pressure), and diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). Review of Resident 326's care plan revealed a focus area of Resident needs dialysis with an intervention for do…

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 resident and staff interviews, it was determined that the facility failed to provide or obtain dental services to meet the needs of each resident for one of one residents reviewed for dental concerns (Resident 80). Findings include: Review of Resident 80's clinical record revealed diagnoses that included congestive heart failure (CHF - weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues) and vitamin deficiency. During an interview with Resident 80 on November 18, 2024, at 10:17 AM, she revealed that she was concerned that the facility did not do routine dental care. She also revealed that she has her own teeth and is used to taking good care of them. Review of dental consult form dated December 1, 2023, revealed that recommended treatment included dental prophy (prophylaxis - dental cleaning and checkup) in six months. Further review of Resident 80's clinical record failed to reveal evidence that any additional dental services were received since her visit on December 1, 2023. During an 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 the clinical record and staff interview it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 10 residents reviewed (Resident 3 and 10). Findings include: Review of Resident 3's clinical record revealed diagnosis to include heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs) and hypertension (high blood pressure). Review of Resident 3's clinical record revealed they were admitted to the facility on [DATE], and discharged home on March 16, 2024. Review of Resident 3's physician orders revealed an order for bath/shower twice weekly every Tuesday/Friday 7:00 AM-3:00 PM shift, with an active date of March 6, 2024. Review of Resident 3's March 2024 Treatment Administration Record revealed the resident received a shower on March 12, 2024. Review of the facility's policy titled,…

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 safe, clean, and comfortable home-like environment for three of 34 resident's reviewed (Resident 2, 18, and 34). Findings include: Observation in Resident 2's room on January 22, 2024, at 9:43 AM, revealed the wall behind her bed was damaged. Additional observation in Resident 2's room on January 23, 2024, at 9:00 AM, revealed the wall behind her bed was damaged. Observation in Resident 18's room on January 22, 2024, at 9:26 AM, revealed her floor was dirty surrounding her bed and behind her bed, and a table across from her bed had a dusty shelf underneath. Additional observation in Resident 18's room on January 23, 2024, at 8:56 AM, revealed her floor was dirty surrounding her bed and behind her bed, and a table across from her bed had a dusty shelf underneath. Observation in Resident 34's room on January 22, 2024, at 9:43 AM, revealed her floor was dirty surrounding her bed and behind her bed, and her privacy curtain was soiled with a brown substance. Additional observation in…

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

Based on observations, review of facility policy, and resident and staff interviews, it was determined that the facility failed to provide residents access to grievance forms within reach for residents who are wheelchair-bound for one of two areas identified (Roosevelt Hall); and failed to post the required information of the Grievance Official for two of two areas identified (Jefferson Hall and Roosevelt Hall). Findings include: Review of facility policy, titled Grievances/Complaints, Filing, last reviewed August 16, 2023, revealed section titled, Policy Interpretation and Implementation stated, .The Administrator has delegated the responsibility of grievance and/or complaint investigation to the Grievance Officer who is (blank) and can be contacted by (blank). Observations of all resident areas conducted on January 22, 23, and 24, 2024, revealed the facility failed to post written information that identified the facility's Grievance Official, the Grievance Official's business mailing and email address, and phone number. Observations of the nursing station on Roosevelt Hall 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 facility policy review, employee record review, and staff interview, it was determined that the facility failed to perform criminal background checks prior to or upon hire for three of five employees reviewed (Employee 6, 7, and 8). Findings include: Review of facility policy, titled Background Screening Investigations, last reviewed August 16, 2023, revealed section 1 stated, The Personnel/Human Resources Director, or other designee, will conducted background checks, reference checks and criminal conviction checks [sic] on all potential employees and contract personnel who meet the criteria for direct access employee [sic]. Such investigations will be initiated within two days of an offer of employment or contract agreement. Review of Employee 6's personnel record revealed that Employee 6 was hired by the facility on October 3, 2023, for the position of Nurse Aide. Continued review of Employee 6's personnel record revealed no Pennsylvania criminal conviction check. On January 25, 2024, the facility submitted a Pennsylvania criminal conviction check for Employee 6 that was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment was accurate for five of 29 residents reviewed (Residents 18, 22, 37, 76, and 125). Findings include: Review of Resident 18's clinical record revealed diagnoses that included Chronic obstructive pulmonary disease (COPD- a group of lung disease that block airflow and make it difficult to breathe), Alzheimer's Disease (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and acute cough. Review of Resident 18's clinical record revealed a physician note dated September 22, 2023, that stated, Resident seen and examined today for a monthly follow up and review of chronic medical conditions including but not limited to COPD .COPD stable at this time .Treat exacerbations with scheduled duonebs (breathing treatments), prednisone burst and antibiotics if indicated. Review of Resident 18's Quarterly…

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

Based on observations, clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 34 residents reviewed (Resident 18, 74, 99, and 100) Findings Include: Review of the facility policy, titled Care Plans, Comprehensive Person-Centered, last reviewed on August 16, 2023, revealed that assessments of resident are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of Resident 18's clinical record revealed diagnoses that included Chronic obstructive pulmonary disease (COPD - a group of lung disease that block airflow and make it difficult to breathe), Alzheimer's Disease (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and acute cough. Observation in Resident 18's room on January 22, 2024, at 9:27 AM, revealed a nebulizer machine (a medical device that delivers liquid medicine into the lungs for people with certain lung disorders)…

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

Based on observation, policy review, staff interviews, and record review, it was determined that the facility failed to ensure that a resident with a pressure ulcer received care consistent with professional standards of practice for two of two Residents reviewed (Residents 45 and 80). Findings include: Review of Resident 45's clinical record revealed diagnoses that included hypokalemia (low potassium) and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of a [NAME] Wound Evaluation and Management Summary completed on June 15, 2023, revealed Resident 45 had a post-surgical back wound measuring 4.0 x 0.5 x 1.0 centimeters (length x width x depth), with a treatment plan for Santyl to be applied once daily for 30 days, mupirocin ointment to be applied once daily for 30 days, alginate calcium to be applied once daily for 30 days, and gauze island with boarder to be applied once daily for 30 days. Review of Resident 45's June 2023 TAR (treatment administration record) revealed Resident 45 did not receive wound care as ordered for…

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

Based on observations, policy review, staff interviews, and clinical record review, it was determined the facility failed to provide oversight and monitoring of parameters of nutritional status and implementation of nutrition interventions for three of 26 residents reviewed (Residents 37, 76, and 80). Findings include: Review of facility policy, titled Fortified Foods, not dated, read, in part, the purpose of utilizing fortified foods is to add additional calories/protein to the diet in efforts to address weight loss, skin status, or nutritional concerns. Fortified foods to be added to the resident diet includes super cereal and super potatoes. These items should be prepared using the recipes within the policy. When fortified foods are provided, intake percentages need to be monitored closely to assure positive outcomes. Review of Resident 37's clinical record revealed diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood 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 observations, policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide respiratory services for three of 32 residents reviewed (Resident 18, 37, and 328). Findings include: Review of facility policy, titled Administering Medications Through a Small Volume Nebulizer, revised October 2010, read, in part, when equipment is completely dry store in a plastic bag with the Resident's name and date on it, change equipment and tubing every seven days. Review of facility provided policy, titled Oxygen Administration, Revised October 2010, revealed that, to prepare for oxygen administration, employees should verify that there is a physician's order for the procedure and review the resident's care plan to assess for any special needs of the resident. The same policy failed to reveal whether oxygen tubing should be labeled. Review of Resident 18's clinical record revealed diagnoses that included Chronic obstructive pulmonary disease (COPD - a group of lung disease that block airflow and make it difficult to breathe),…

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

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity was reviewed and acted upon for five of 26 residents reviewed for unnecessary medications (Residents 4, 22, 63, 76, and 81). Findings include: Review of facility policy, titled Medication Regimen Reviews, revised April 2007, read, in part, the Consultant Pharmacist will document his/her finding and recommendations on the monthly drug/medication regimen review report. The Consultant Pharmacist will provide a written report to physicians for each resident with an identified irregularity . If the physician doesn't provide a pertinent response, or the Consultant Pharmacist identified that no action has been taken, he/she will then contact the Medical Director or the Administrator. The Consultant Pharmacist will provide the Director of Nursing (DON) and Medical Director with a written signed and dated copy of the report listing the irregularities found and recommendations for their solutions.…

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

Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure one of four residents reviewed were free of unnecessary psychotropic medications (Resident 42). Findings include: Review of facility policy, titled Antipsychotic Medication Use, revised December 2016, read, in part, the attending physician will evaluate and document with input from other disciplines and consults as needed. Nursing staff will monitor for and report any side effects to the attending physician. Review of Resident 42's clinical record contained diagnoses that included dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), history of alcohol abuse, anxiety (a feeling of worry, nervousness, or unease), depression (feelings of severe despondency and dejection), and bipolar (a mental health condition alternating periods of elation and depression). Review of Resident 42's physician orders included: Wellbutrin 300 milligrams (mg) once daily for depression, started June 28, 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 observations, resident and staff interviews, policy review, and record review, it was determined that the facility failed to provide routine and emergency dental services for one of 29 residents reviewed (Resident 22). Findings include: Review of the facility policy, titled Dental Services, with a review date of August 16, 2023, revealed a policy statement of routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Review of Resident 22's clinical record revealed diagnoses that included type two diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) and hypertensive chronic kidney disease (high blood pressure caused by damage to the kidneys) with stage five chronic kidney disease (kidneys are close to or have already failed). During an interview with Resident 22 on January 22, 2024, at 1:15 PM, an observation was made of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety for two of three pantry refrigerators ([NAME] and Phoenix pantries). Findings include: Observation in the [NAME] unit pantry on January 22, 2024, at 9:36 AM, with Employee 12 (Food Service Director) revealed one container on high calorie liquid nutritional supplement was opened with contents partially removed and was not date marked with an open or use by date. During an interview with Employee 12 on January 22, 2024, at 9:36 AM, it was revealed that she checks the pantries daily and if anything is not date marked with an open date, it is disposed of. Observation in the Phoenix refrigerator on January 22, 2024, at 10:03 AM, there was one 45 ounce applesauce that was opened with contents partially removed and not date marked with an open or use by date. During an interview with Employee 9 (Unit Manager) on January 24, 2024, at 1:53 PM,…

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 document review and staff interviews, it was determined that the facility failed to hold Quality Assurance Committee meetings at least quarterly for two of four quarters reviewed (First Quarter of 2023 and Second Quarter of 2023). Findings include: Review of the facility's Quality Assurance and Performance Improvement Plan (QAPI), for 2023-2024, revealed it stated, QAPI Committee meetings will be conducted monthly .QAPI Leadership will assure that minimal committee membership is met and will periodically monitor that resources are available to support QAPI activities .A quarterly QAPI activities summary will be reviewed and approved by the QAPI Committee. Quarterly updates will be communicated to organizational leadership, staff, residents and families. Review of all available documentation submitted by the facility revealed no evidence that the facility conducted a Quality Assurance Committee meeting during the first quarter (January, February, March) and the second quarter (April, May, June) of 2023. During a staff interview on January 25, 2024, at approximately…

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

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to ensure implementation of an effective infection control program and ensure staff implemented infection control policies to prevent the spread of infection by wearing required PPE (personal protective equipment) and hanging correct signage for one of two residents observed (Resident 326). Findings Include: Review of facility policy, titled Monitoring Compliance with Infection Control, last revised September 2017, revealed The infection preventionist or designee shall monitor the effectiveness of our infection prevention and control work practices and protective equipment. This includes but is not necessarily limited to .effective implementation of hand hygiene practices by all departments to prevent the spread of infections .effective use of disposable gloves and other personal protective equipment to prevent spread of infection. Review of facility policy, titled Handwashing/Hand Hygiene, last revised December 2012, revealed hand hygiene should be performed before…

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 interview, it was determined that the facility failed to ensure that residents have the right to a dignified existence for two of 34 resident's reviewed (Resident 2 and 80). Findings include: Observation on January 22, 2024, at 12:11 PM, the surveyor overheard Employee 2 (Housekeeper) say to Employee 3 (Licensed Practical Nurse), If the door is open, I am not going to knock. Observation of Employee 2 on January 22, 2024, at 12:13 PM, the surveyor observed her entering Resident 2 and 80's room without knocking or notifying of entry. During an interview with the Director of Nursing on January 23, 2024, at 1:43 PM, she revealed she would expect employees to knock prior to entering Residents' rooms. 28 Pa Code 201.29(d) Resident Rights

Based on record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that resident needs were accommodated regarding call bell accessibility for two of 34 residents reviewed (Residents 18 and 34). Findings include: Review of Resident 18's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), anxiety (a feeling of worry, nervousness, or unease), and hypertension (high blood pressure). Review of Resident 18's care plan revealed a focus area: The resident is at moderate risk for falls related to confusion, gait/balance problems related to non-weight bearing right leg, last revised March 10, 2023, with an intervention for be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, last revised March 10, 2023. Observation in Resident 18's room on January 22, 2023, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interviews, it was determined that the facility failed to develop a comprehensive plan of care for three of 26 residents reviewed (Residents 26, 37, and 51). Findings include: Review of Resident 26's clinical record on January 23, 2024, at approximately 10:00 AM, revealed diagnoses that included hypertension (elevated/high blood pressure) and congestive heart failure (CHF - decreased ability of the heart to pump blood throughout the body, resulting in excess fluid buildup throughout the body). Review of Resident 26's clinical record revealed Resident 26 had a Foley catheter (tube placed in the urinary bladder through the urethra to facilitate draining of urine into an external collection bag). Review of Resident 26's comprehensive plan of care on January 24, 2024, at approximately 12:30 PM, revealed that Resident 26 did not have a care plan that addressed the use of a Foley catheter. During a staff interview on January 25, 2024, at approximately 12:00 PM,…

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, facility policy review, and resident and staff interviews, it was determined that the facility failed to provide care and services regarding facial shaving for two of thirty-two residents reviewed (Resident 41 and 122). Findings include: Review of facility policy, titled Activities of Daily Living (ADLs), Supporting, without revision date, revealed, Residents who ae unable to carry out activities of daily living (ADL's) independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of Resident 41's clinical record revealed diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and lack of coordination (Uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements). Observation of Resident 41 on January 22, 2024, at 11:17 AM, revealed that she had long and thick facial hair. Observation of Resident 41 on January 23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure each resident receives proper treatment and assistive devices to maintain hearing abilities for one of 26 residents reviewed (Resident 37). Findings include: Review of Resident 37's clinical record revealed diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), anxiety (a feeling of worry, nervousness, or unease), age related macular degeneration (a degenerative condition affecting the central part of the retina, resulting in distortion or loss of central vision), glaucoma (a condition of increased pressure within the eyeball causing general loss of sight), dysphagia (difficulty swallowing), and heart failure (the heart doesn't pump blood as well as it should). During an interview with Resident 37 on January 22, 2024, at 12:58…

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 and staff interview, it was determined that the facility failed to provide restorative nursing care for range of motion exercises for one of 34 residents reviewed (Resident 100). Findings include: Review of Resident 100's clinical record revealed diagnoses that included essential hypertension (high blood pressure) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of a fall incident report completed on Resident 100 on December 7, 2023, revealed an intervention for Resident 100 to be screened by therapy post-fall. Review of a Physical Therapy evaluation and plan of treatment completed on Resident 100 on December 8, 2023, under the assessment summary, revealed recommendations that Resident 100 would benefit from a restorative nursing program with nursing staff for ambulation with rolling walker to maintain functional mobility. Review of a Rehabilitation Service Restorative Nursing/Functional Maintenance Referral completed on Resident 100 on January 5, 2024, revealed a range…

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

Based on policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure residents receive appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of 32 residents reviewed (Resident 327). Findings include: Review of facility provided policy, titled Catheter Care, Urinary, revised September 2014, revealed, Be sure to catheter tubing and drainage bag are kept off the floor. Review of Resident 327's clinical record revealed diagnoses that included urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra) and malignant neoplasm of cervix (malignant tumor of the cervix, the lowermost part of the uterus). Observation of Resident 327 on January 22, 2024, at 9:50 AM, revealed the Resident lying in bed and their catheter was lying on the floor. Observation of Resident 327 on January 22, 2024, at 11:26 AM, revealed the Resident lying in bed and their catheter was lying on the floor. Observation of Resident 327…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, manufacturer information, facility policy review, and staff interview, it was determined that the facility failed to ensure adherence to medication expiration dates (use by dates) and failed to ensure appropriate labeling of medication when opened for one of one medication storage rooms observed ([NAME] Hall). Findings include: Review of facility policy, titled Storage of Medications, last revised August 16, 2023, stated discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Observation of the [NAME] Hall medication storage room refrigerator on January 23, 2024, at 10:33 AM, revealed one box of Tuberculin purified protein (Tubersol) (substance that's used to detect exposure to tuberculosis) containing a multi-use vial that was open and partially used. No open date was documented on the box or vial. Further, observation revealed a second box of Tuberculin purified protein (Tubersol) containing a multi-use vial that was open 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 observations, policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide adaptive feeding devices for one of 26 residents reviewed (Resident 37). Findings include: Review of facility policy, titled Adaptive Self-Feeding Devices, not dated, read, in part, dietary department will be responsible for placing the devices on resident's tray as needed. Review of Resident 37's clinical record revealed diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), anxiety (a feeling of worry, nervousness, or unease), age related macular degeneration (a degenerative condition affecting the central part of the retina and resulting in distortion or loss of central vision), glaucoma (a condition of increased pressure within the eyeball causing general loss of sight), dysphagia (difficulty swallowing), chronic ulcer of left foot (open area), osteoarthritis (degeneration 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, facility provided information, clinical records, and resident and staff interviews, it was determined that the facility failed to ensure that, in preparation for room changes, each resident received written notice, including the reason for the change, before the resident's room was changed for one of one residents reviewed (Resident 1). Findings include: Review of facility policy, titled Transfer or Discharge Notice, with a revised date of December 2016, revealed the following: 2. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge .; 2f. An immediate transfer or discharge is required by the resident's urgent medical needs .; 3. The resident and/or representative will be notified in writing of the of the following information: a) the reason for the transfer or discharge, b) the effective date of the transfer or discharge, c) the location to which the resident is being transferred or discharged ; and 10. At time of notification, the facility will provide each resident and…

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

Based on facility policy review, facility documentation review, clinical record review, and resident and staff interviews, it was determined the facility failed to ensure each resident is free from mental abuse for one of four residents reviewed (Resident 1). Findings Include: Review of facility policy, titled Abuse Prevention Program, with a last revised date of December 2016, revealed, in part: As part of the resident abuse prevention, the administration will: 1) Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual; and 5. Implement measures to address factors that may lead to abusive situations, for example: a. Provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation; and b. Instruct staff regarding appropriate ways to address interpersonal conflicts. Mental abuse is defined as the use of verbal or nonverbal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility policy review, as well as resident and staff interviews, it was determined that the facility failed to provide food that was palatable and at a safe and appetizing temperature for one of one meal observed on the [NAME] Hallway. Findings include: Review of facility policy, titled Food Temperatures revealed, The point of service temperature to residents will be within the range of 120-140 degrees based on the resident's preference. During an interview with Resident 5 on August 24, 2023, at 10:42 AM, they revealed that they didn't consider the food to be appetizing. During an interview with Resident 2 on August 24, 2023, at 11:39 AM, they stated that the food is always cold. During an interview with Resident 6 on August 24, 2023, at 12:45 PM, they stated that they do not like the food. During an interview with Resident 7 on August 24, 2023, at 1:05 PM, they stated that the food is always cold. During an interview Resident 8 on August 24, 2023, at 1:30 PM, they stated that their lunch…

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