Milford Rehabilitation And Healthcare Center

Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review a facility policy entitled Food Receiving and Storage last reviewed by the facility on April 23, 2025, indicated that opened food items would include a use by date and all dry foods…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policy, and staff interviews, it was determined the facility failed to implement procedures to ensure the timely acquisition and administration of prescribed medications for one of 18 sampled residents (Resident 15). Findings include: A review of facility policy labeled Administering Medications last reviewed April 23, 2025, revealed medication are administered in accordance with prescriber orders including any required time frame. A review of Resident 15's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included Dementia (the loss of cognitive functioning that affects a person's ability to perform everyday activities). A review of physician's orders dated May 13, 2024, revealed the physician prescribed Lactaid Fast oral Tablet 9000 units (an enzyme used to help break down lactose the natural sugar in milk and dairy products). Give one by mouth with meals for lactose intolerance (inability of the body to digest…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy and staff interview it was determined the facility failed to ensure the pharmacist conducted medication regimen reviews at least monthly for two residents out of five sampled.(Resident 48 and 42). Findings include: A review of a facility policy entitled Medication Regime Reviews last reviewed by the facility on April 23, 2025, indicated the facility's consultant pharmacist conducts monthly medication regime reviews (MRR) for each resident at least monthly. The MRR involves a thorough review of the resident's medical record to prevent, identify, report and re-solve medication related problems, medication errors and other irregularities, for example medications ordered in excessive doses or without clinical indication, medication regimens that appear inconsistent with the resident's stated preferences, duplicative therapies or omissions of ordered medications, inadequate monitoring for adverse consequences, potentially significant drug-drug or drug-food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined the facility failed to ensure that residents' drug regimens were free from unnecessary medications by failing to discontinue an unnecessary antibiotic for one resident (Resident 22); failing to provide clinical justification for the use of duplicate antidepressant medications for one resident (Resident 42); and failing to ensure that one resident's (Resident 48) medication regimen was free from unnecessary psychoactive medication, including administering an as-needed antianxiety medication beyond 14 days without adequate clinical justification and without documentation of attempted non-pharmacological interventions, for three of eighteen sampled residents. Findings include: A review of Resident 22's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis to include dementia (a decline in memory, thinking, and other cognitive abilities, significantly impacting daily life) and chronic kidney disease (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of grievances, select facility policy and resident and staff interviews it was determined the facility failed to demonstrate timely and adequate efforts to resolve resident grievances for one resident out of 5 sampled. (Resident 1) Findings include: A review of the facility policy entitled Grievances/Complaints, dated as reviewed April 29, 2024, revealed, residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. Any resident, family or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will 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 observation and staff interview, it was determined that the facility failed to properly dispose of garbage and refuse. Findings include: Observation on August 13, 2024, at 10:20 AM in the presence of the food service director revealed that the facility's dumpster, containing bags of garbage, was not covered. One of the two lids on the dumpster was observed open. There were food containers and debris scattered on the ground surrounding the dumpster. Interview with the food service director at this time confirmed that the dumpster lid was to be kept closed and that the area surrounding the dumpster should be maintained in a sanitary manner. 28 Pa Code 201.8 (e)(2.1) Management

Based on clinical record review, observation, and staff interviews, it was determined 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 one of 16 residents reviewed (Residents 51). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. Review of Resident 51's clinical record revealed admission to the facility on December 6, 2023, with diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of an incident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policy and clinical records, and staff interview, it was determined the facility failed to timely notify the physician and the resident's representative of an incident with the potential to require physician intervention for one resident out of 16 sampled (Resident 115). Findings include: A review of the facility Change in Resident's Condition or Status Policy last reviewed, June 2024, revealed it is the policy of the facility to promptly notify the resident, his or her attending physician, and resident representative of changes in the resident's medical/mental condition and/or status. A review of the clinical record revealed Resident 115 was discharged from the facility to the hospital on July 27, 2024, and readmitted to the facility on [DATE], with diagnoses which included a urinary tract infection, cerebral infarction (stroke), and seizures. A Midline catheter (a long, thin, flexible tube that is inserted into a vein in the upper arm to safely administer medication or fluids…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, and staff interview, it was determined the facility failed to address a resident's skin condition on the comprehensive care plan for one out of 16 sampled residents (Resident 23). Findings include: A review of the clinical record revealed Resident 23 was admitted to the facility on [DATE], with diagnoses which include congestive heart failure, cerebrovascular accident (CVA- stroke, interruption in the flow of blood to cells in the brain), and rheumatoid arthritis. A physician order dated June 27, 2024, noted an order to apply Zinc to buttocks every shift for skin protectant/moisture barrier. A wound progress note dated August 1, 2024, indicated the resident's sacrum (large, triangle-shaped bone in the lower spine that forms part of the pelvis) was assessed and was noted to have MASD (Moisture-associated skin damage caused by prolonged exposure to various sources of moisture, including urine or stool, or perspiration) of the epidermis resulting from prolonged exposure 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 review of clinical records, select facility reports, observations and staff interview it was determined the facility failed to consistently provide care and services to to prevent the development and/or worsening of pressure sores and promote healing for one resident out of 16 residents sampled (Resident 6). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and select facility policy, staff and resident interviews it was determined the facility failed to ensure that a physician ordered intravenous (IV- medication is administered through needle or tube inserted into a vein) medication, an antibiotic, was timely administered as prescribed for one resident out of 16 sampled (Resident 115). Findings include: Review of the facility policy titled Administering Medications last reviewed by the facility on June 24, 2024, indicated that medications are administered in a safe and timely manner and as prescribed. It indicated that medications are administered in accordance with prescriber orders, including any required time frame. Medication errors are documented, reported, and reviewed by the QAPI (Quality Assurance and Performance Improvement) committee to inform process changes and/or the need for additional staffing. Prescribed medications are to be administered within one hour of their prescribed time, unless otherwise specified.…

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

Based on observations, clinical record review and staff interview it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for a resident receiving hemodialysis for one of 16 residents sampled. (Resident 6) Findings include: According to the National Kidney Foundation patients receiving hemodialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) should keep emergency care supplies on hand. A review of Resident 6's clinical record revealed that the resident was admitted to the facility was on June 10, 2022, with diagnoses that included end stage renal disease (a chronic kidney disease that occurs when the kidneys can no longer function properly) and dependence on renal dialysis. Review of the resident's current plan of care, dated June 11, 2022, and last revised May 22, 2024, revealed that the resident required dialysis related to end stage renal failure along with a care planned approach to have emergency clamp kept at bedside for access site,…

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 each resident received the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one of 15 residents sampled (Resident 59). Findings include: A review of Resident 59's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including unspecified dementia (a loss of cognitive functioning that can make it difficult for someone to perform daily activities). Further review of Resident 59's clinical record revealed that the resident exhibited behaviors, including making statements regarding suicidal ideations. Review of Resident 59's care plan, initiated by the facility on May 18, 2024, did not indicate that the resident had a behavioral problem. The resident's care plan did not address the resident's specific behavioral problems or symptoms that were noted in the nursing documentation. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview it was determined that the facility failed to provide pharmacy services to assure timely receiving of a prescribed antibiotic medication for one resident out of 16 residents reviewed (Resident 115). Findings include: Review of clinical record revealed that Resident 115, was readmitted to the facility on [DATE], with diagnoses to include urinary tract infection and sepsis (extreme immune response to infection that can lead to tissue damage, organ failure, or death if not treated right away). A physician order dated August 8, 2024, at 12:44 PM was noted for Ceftazidime (an antibiotic used to treat bacterial infections) 1000 MG intravenously (a method of administering a substance, such as medicine or fluid, into a vein through a needle or tube) two times per day for urinary tract infection for three days. Review of a Scheduling Detail Report dated August 8, 2024, noted that the first dose was to be administered on August 8, 2024, at 10:00 PM. Review 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 a review of the results of facility water testing for safe drinking water and interviews with laboratory staff and facility staff it was determined the facility failed to comply with requirements from the Environmental Protection Agency (EPA) and Pennsylvania Department of Agriculture and Pennsylvania Drinking Water Information System (PADWIS) in conjunction with the Title 25 Pa. Code Chapter 109 Subchapter C Monitoring Requirements relating to Title 40, Code of Federal regulations 40 CFR. Findings included: According to the PADWIS the facility received violations regarding the failure to monitor/report routine samples for specific contaminates for 30 types of contaminates resulting in a violation for each contaminant on July 23, 2024. Interview with the Certified Water Systems Operator/Laboratory Director on July 26, 2024, at 10:30 AM revealed that the facility was required to have SOC (synthetic organic chemical) testing of their drinking water. The SOC samples were to be performed once every three years during the second quarter of the year. The Lab Director stated that…

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

Based on facility policy review, observations, and staff interviews, it was determined the facility failed to store food items under sanitary conditions in the facility's kitchen and two of two resident pantry areas (first and second floors). Findings include: Review of facility policy, titled Food Receiving and Storage, policy and procedure review date of January 29, 2024, included the following but not limited to: Food items and snacks kept on the nursing units must be maintained as indicated below: a. All food items to be kept below 41 degrees F must be placed in the refrigerator located at the nurses' station and labeled with a use by date. b. All foods belonging to residents must be labeled with the resident's name, the item and the ''use by' date. c. Refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines. d. Beverages must be dated when opened and discarded after twenty-four (24) hours. e. Other opened containers must be dated and sealed or covered during storage. f. Partially eaten food may not be kept in the…

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

Based on observation, review of clinical records, and resident and staff interviews it was determined the facility failed to provide physician ordered nutritional supplementation as prescribed to promote adequate nutritional status and paramaters of three out of 11 sampled residents sampled (Residents A4, A5, and A6 ). Findings include: A review of Resident A4 clinical record revealed a physician's order dated February 13, 2024 for Ensure, a nutritional supplement, scheduled for administration to the resident at 2:00 PM daily. It was noted that the supplement will be labeled in the medication room and Boost, another nutritional supplement product, was allowed as a substitution. During an observation of the first floor medication room on March 26, 2024, at 9:15 AM revealed three nutritional supplements, two Boost supplements and one Ensure supplement labeled with Resident A4's name and dated for administration to the resident on March 15, March 16, and March 17, 2024. However, a review of Resident A4's MAR (medication administration record) revealed that staff documented 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 observation, review of select facility policy and staff interview it was determined the facility failed to store and maintain oxygen equipment in a safe, functional and sanitary manner on the second floor nursing unit and in the general storge area. Findings include: A review of the undated facility policy, provided during the survey ending March 26, 2024, entitled Oxygen Storage Policy revealed oxygen tanks are to be stored in an area that is well ventilated, dry and away from sources of heat, open flames or flammable materials. Empty tanks can be stored in a secured medication room and or treatment room until maintenance and or designee is notified to collect and take the designated to the storage location. An observation on March 26, 2024, at 9:30 AM revealed four oxygen cylinders located in the medication/panty area on the second floor. Two of the cylinders had white plastic caps on the valve posts of the metal oxygen cylinder to indicate the cylinder was not used or full. The other two cylinders had regulators (device attached to oxygen tank post used to deliver 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 observation and staff interview, it was determined that the facility failed to ensure adherence to use by/expiration dates of pharmaceutical products in the facility's central supply room. Findings include: Observations of the facility's central supply room on [DATE], at approximately 10:00 AM revealed 35 bottles of Hydrogen Peroxide that expired [DATE]. There were 10 IV starter kits that expired [DATE]. An interview with DON (director of nursing) on [DATE], at the time of the observation confirmed the pharmacy supplies expired and should have been discarded. During an interview with the Nursing Home Administrator on [DATE] at approximately 3:30 PM confirmed expired pharmacy products should have been removed from the storage room and discarded. 28 Pa. Code 211.12 (d)(3)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interview, it was determined that the facility failed to timely notify a resident's representative of a significant change in condition and the need to potentially commence a new form of treatment for one resident out of 17 sampled (Resident 1). Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Resident 1's quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 9, 2023, revealed that the resident was moderately cognitively impaired. A nursing note dated December 28, 2023, at 7:38 PM revealed that the resident was seen by the physician and a…

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

Based on review of clinical records and select facility policy, and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medications to one of 17 sampled residents (Resident 4). Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. A review of the clinical record of Resident 4 revealed admission to the facility on February 6, 2024, with diagnoses, which included…

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, resident and staff interviews, and information provided by the facility it was determined the facility failed to ensure that essential heating equipment was maintained in safe and functional operating condition affecting at least five resident rooms out of 40 resident rooms in the facility (room [ROOM NUMBER], 105, 107, 108 and 210) and failed to maintain resident care equipment, tubs and showers, in operating condition on one of two floors (first floor). Findings include: A review of weather temperatures for the facility's locality revealed that the outdoor temperatures were at a high of 14 degrees Fahrenheit on January 20, 2024. Interview with the facility's Maintenance Director during the survey of January 24, 2024, revealed that the facility's boiler went down on January 20, 2024, resulting in a lack of heat in five resident rooms in the building. The Maintenance Director stated the boiler has an automatic water feed that malfunctioned on that date. He stated when he arrived at 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 resident and staff interview, it was determined that the facility failed to consistently maintain a safe environment for staff, residents and the public by failing to implement safe interim measures during a boiler malfunction resulting in the loss of heat in six resident rooms out of 40 resident rooms in the facility (Rooms 101,104, 105, 107, 108, and 210) Findings include: During interview conducted on January 24, 2024, at approximately 10 AM, the facility Maintenance Director stated during a boiler malfunction on Saturday Janaury 20, 2024, which resulted in the loss of heat to select resident rooms portable space heaters were used in resident rooms on January 20, 2024, and again on January 23, 2024, due to an issue with a heater in one resident's room. According to interview with the Maintenance Director on January 24, 2024, the facility's facility boiler system malfunctioned on January 20, 2024, which resulted in the failure to provide heat via PTAC systems (PTAC self-contained heating and air…

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, a review of clinical records and select facility documentation, and resident and staff interviews, it was determined the facility to consistently provide maintenance services to assure a clean, safe, orderly, and comfortable interior, including comfortable room temperatures, on two of two resident units (first and second floor) affecting six out of 40 resident rooms in the facility (Rooms 101,104, 105, 107, 108, and 210) Findings included: During a tour of the facility conducted on January 24, 2024, random interviews were conducted with residents residing on both the second between 9 AM and 11 AM. Multiple residents reported that during the past weekend, Saturday January 20, 2024, and Sunday Janaury 21, 2024, the heat was not working in the facility and that it was very cold inside the building. A review of the weather forecast for the facility's locality on January 20, 204, revealed that the temperature was approximately 14 degrees Farenheit with a lower wind chill temperature. A 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, the facility's abuse prohibition policy, select facility incident reports, and information submitted by the facility, and staff interview, it was determined that the facility failed to ensure that one resident out of 8 resident sampled was free from physical abuse (Resident 2). Findings include: Review of facility's abuse policy Policy Interpretation and Implementation last revised by the facility August 2022, revealed that the resident has the right to be free from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion. With abuse being defined as Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Willful, as used in this definition of abuse,…

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 and staff interview, it was determined that the facility's dietary services department failed to maintain acceptable sanitary practices when handling and preparing food and handling clean dishware/cookware to prevent the potential for contamination and microbial growth in food. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). During a tour of the dietary department, in the presence of the dietary manager, conducted on January 3, 2024, at 10:25 AM, revealed that there were two bearded dietary employees without…

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 interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a clean and sanitary environment in resident areas on two of two resident units (First floor and Second floor nursing units) Findings include: Observations on the First Floor Nursing Unit on September 12, 2023, at approximately 11:00 AM, revealed in resident room [ROOM NUMBER] the molding next to the heating and cooling unit was peeling off. The plaster on the wall next to the heating and cooling unit was crumbling. The vinyl floor was worn through, and black marks were showing and several of the vinyl floor planks were lifting from the flooring beneath. In resident room [ROOM NUMBER] the baseboard heater covers were dented scratched and falling off the units. There was a hole in the vinyl flooring. There was a black mold-like substance in the corner on the ceiling and wall by the window. In resident room [ROOM NUMBER] the molding was peeling away from 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 and staff interview it was determined that the facility failed to develop a comprehensive plan to address the behavioral health needs of two of 15 sampled residents (Residents 34, and 30). Findings include: Review of clinical record of Resident 34 revealed that the resident was admitted to the facility on [DATE], with diagnoses including alzheimer's disease. Further review of Resident 34's clinical record revealed that the resident exhibited multiple behaviors, including exit seeking, physically aggressive with staff, and hypersexual behaviors. Resident 34 was noted to have an increase in these behaviors beginning July 2023, according to a review of progress notes, culminating in multiple incidents including August 26, 2023, resident was the perpetrator in a sexual incident with a resident in which he grabbed a female resident's breasts, and on September 2, 2023, the resident eloped from facility. Review of Resident 34's nursing progress notes in the resident's clinical record…

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 and staff interview, it was determined the facility failed to store patient care equipment in an orderly and sanitary manner to maintain the equipment in safe operating condition. Findings include: A tour of the facility's resident storage area on September 12, 2023, at approximately 9:00 AM revealed a 2 bay garage the facility used to store resident equipment. Inside the storage area revealed multiple resident mattresses and wheelchairs that were covered in dirt and debris. The mattresses were lying directly on the dirty concrete floor. some of the mattresses and wheelchairs were coated with a fuzzy mold-like film. The storage area felt very damp and had a strong mildew smell. Outside of the garage area there was resident bedside and overbed tables, a bed alarm pad, and an air mattress and air pump covered in water and debris. An interview with the Nursing Home Administrator (NHA) on September 12, 2023, at 9:30 AM revealed NHA was unable to explain why the resident care equipment was stored in this manner and that it should be properly stored and maintained 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 observation and staff interview, it was determined that the facility failed to maintain a safe and sanitary environment on the facility grounds. Findings include: Observations of the facility grounds by the double garage that the facility calls the boat house on September 12, 2023, at approximately 9:00 AM revealed broken tile, broken pieces of wood, water saturated sheet rock, a medical basin filled with water and algae, multiple pieces of construction material strewn throughout the ground, disposable medical gloves, a headboard to an electric bed, bags and boxes of garbage, broken pallets, plastic pieces, large plastic bins, broken metal folding chairs, a rusty pickaxe, a tub of chlorine tablets, garbage strewn through out the ground, clumps of wet paper, plastic bags, a broken garage door, a large wire rack, and multiple five gallon buckets. During an interview on September 12, 2023, at approximately 9:30 AM, the Nursing Home Administrator stated she was unaware of the condition of the facility grounds and confirmed the facility failed to maintain a safe and sanitary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, information submitted by the facility and the facility's abuse prohibition policy, and staff interview, it was determined that the facility failed to ensure that residents were free from sexual abuse as evidenced by one of 15 sampled residents (Resident 41) Findings include: Review of facility abuse policy titled Policy Interpretation and Implementation last revised in August 2022, revealed that the resident has the right to be free from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion. Sexual abuse is defined as, but not limited to, non-consensual sexual harassment, sexual coercion, contact or sexual assault. Clinical record review revealed that Resident 34 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life) According to the resident's quarterly Minimum Data Set assessment…

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, a review of clinical records, select facility policy, resident incident/accident reports and information submitted by the facility and staff interviews, it was determined that the facility failed to provide adequate staff supervision and effective safety measures to prevent a resident's elopement one resident (Resident 34) and failed to maintain an environment free of accident hazards resulting in a fall for one resident (Resident 14) out of 15 reviewed. Findings included: A review of Resident 34's clinical record revealed admission to the facility on October 7, 2022, with a diagnosis of Alzheimer's disease. Review of resident 34's clinical record revealed an elopement assessment completed on July 11, 2023, due to an increase in exit seeking behavior displayed by the resident. The resident was assessed to be at high risk for elopement. A wanderguard bracelet was applied to the resident's left ankle on July 10, 2023. Review of resident's clinical record revealed that the resident displayed consistent behaviors of attempting to leave the second floor of 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 a review of the facility's abuse prevention policy and clinical records and staff interview, it was determined that the facility failed to develop and implement written and procedures for screening prospective residents to ensure the facility is aware of the necessary services required to care for one out of 10 residents sampled. (Resident 1). Findings include: Federal regulatory intent under CFR 483.12 (b) indicates that a facility must develop and implement policies and procedures to prohibit and prevent both abuse and neglect. This would include screening prospective residents to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. Review of clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses which included congestive heart failure, diabetes, and acquired absence of right leg above the knee. Resident 1 had resided out of state prior to admission. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview it was determined that the facility failed to ensure that the care plan of one resident out of 10 reviewed included planned interventions for staff implementation to maintain the desired outcome of the safety of others (Resident 1). Findings include: Review of clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses, which included congestive heart failure, diabetes, and acquired absence of right leg above the knee. Further review of the clinical record revealed that Resident 1 was a convicted sex offender, involving a child. An interdisciplinary team care plan note dated April 18, 2023, at 10:10 a.m. revealed that during discharge planning discussion, Resident 1's wife stated that she will not have her husband home with her because, there is a small problem. The landlord doesn't want him. According to the documentation, it was brought to the facility's attention that Resident 1 was on the convicted sex offender…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and incident reports, observations and staff and interview it was determined that the facility failed to timely and consistently provide services necessary to prevent pressure sore development and promote healing for one out of 10 residents sampled with pressure injuries (Resident CR1). Findings included: Review of Resident CR1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of unspecified dementia [a group of symptoms that affects memory, thinking and interferes with daily life], unspecified psychosis [is the term for a collection of symptoms that happen when a person has a disconnection from reality and can occur due to different mental and physical conditions], and kidney disease. A review of the resident's initial admission/readmission assessment section 8 - skin evaluation dated May 8, 2023, at 12:22 PM, indicated that the resident was at high risk for the development of pressure ulcers due to occasional moisture 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview with facility staff, it was determined that the facility failed to evaluate the clinical necessity of an indwelling urinary catheter for of one out of 10 sampled (Resident CR1). Findings included: Review of a facility entitled Urinary Continence and Incontinence - Assessment and Management indicated that the staff and practitioner will appropriately screen for and manage individuals with urinary incontinence and that management of incontinence will follow relevant clinical guidelines. The physician and staff will provide appropriate services and treatment. Indwelling urinary catheters will be used sparingly, for appropriate indications only. As part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary continence. Examples of sources of such information may include the resident, family, or a hospital discharge summary describing placement of an indwelling catheter during a recent hospitalization. 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.