Northern Dauphin Nursing And Rehabilitation Center

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide personal care and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for seven of fifteen residents reviewed (Resident 5, 6, 7, 8, 9, 10, and 11). Findings include: Interview conducted with NA 3 on December 9, 2024, at approximately 1:17 PM, revealed they do not feel the facility has enough staff to provide care and showers to the residents that are assigned to them the majority of the time, especially on second shift. Interview conducted with Nurse Aid 2 (NA 2) on December 10, 2024, at approximately 1:55 PM, revealed they do not feel the facility has enough staff to care for the residents who are assigned to them most of the time. Review of Resident 5's clinical record revealed diagnoses that included dementia (a group of symptoms affecting memory, thinking, and social abilities) and depression (mood disorder that causes a persistent feeling of sadness 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 clinical record reviews and staff interview, it was determined that the facility failed to obtain laboratory services for one of 15 residents reviewed (Resident 3). Findings include: Review of Resident 3's clinical record revealed diagnoses that included heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the body's organs) and major depressive disorder (a serious mental health condition that affects how a person feels, thinks, and acts). Review of Resident 3's clinical record revealed a fall incident progress note on November 1, 2024, at 7:54 PM, that read, in part, nursing did request a urine to be obtained due to history of urinary tract infections (UTIs). Further review of Resident 3's clinical record revealed an interdisciplinary progress note on November 4, 2024, at 11:38 AM, that read, in part, members of the interdisciplinary team reviewed Resident 3's fall that occurred on November 1, 2024. Medical director made aware with new order received to obtain urine analysis and culture sensitivity test (UA C&S) to rule…

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, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure resident privacy was protected for one of five residents reviewed, after a video baby monitor was placed in a resident's room (Resident 3). Findings include: Review of facility policy, titled Resident Rights, revised June 2023, revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: privacy and confidentiality. Review of Resident 3's clinical record revealed that he was admitted to the facility on [DATE], with diagnoses that included frontotemporal neurocognitive disorder (the result of damage to neurons in the frontal and temporal lobes of the brain. Many possible symptoms can result, including unusual behaviors, emotional problems, trouble communicating, difficulty with work, or difficulty with walking) and Bipolar disorder (a disorder associated with episodes of mood swings…

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

Based on a review of facility documents it was determined that the facility failed to ensure sufficient nursing staff to comply with state laws regarding mandated minimum staffing requirements. Findings include: Review of 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, dated February 23, 2023; with an effective date of July 1, 2023, indicated the following subsections. (f.1) In addition to the director of nursing services, a facility shall provide all of the following: (2) Effective July 1, 2023, a minimum of 1 nurse aide (NA) per 12 residents during the day, 1 NA per 12 residents during the evening, and 1 NA per 20 residents overnight. (3) Effective July 1, 2024, a minimum of 1 NA per 10 residents during the day, 1 NA per 11 residents during the evening, and 1 NA per 15 residents overnight. (4) Effective July 1, 2023, a minimum of 1 LPN (licensed practical nurse) per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight. (i) A minimum number of general nursing care hours…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident or their representative received written notice of the facility bed-hold policy at the time of transfer for one of nine residents reviewed (Resident 9), and failed to ensure that the written notice of the facility bed-hold policy at the time of transfer included the reserve payment required for four of nine residents (Residents 3, 4, 9, and 136). Findings Include: Review of Resident 3's clinical record revealed diagnoses that included hypertension (high blood pressure), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Further review of Resident 3's clinical record revealed that on May 29, 2024, the Resident was transferred out of the facility to the hospital and was subsequently…

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, record review, and resident and staff interviews, it was determined that the facility failed to ensure the resident's right to participate in the care planning process, and failed to review and revise the resident plan of care for two of 31 resident's reviewed (Residents 10 and 125). Findings include: Review of facility policy, titled Care Plans, Comprehensive and Person-Centered, last revised September 2022, read, in part, The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care including the right to participate in the planning process and request meetings. The care planning process will facilitate resident and/or representative involvement. Assessments of residents are ongoing and care plans are revised as information about the 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 clinical record review and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for two of 31 residents reviewed (Residents 10 and 136). Findings include: Review of Resident 10's clinical record revealed diagnoses that included atrial fibrillation (a disease of the heart characterized by irregular and often faster heartbeat), chronic obstructive pulmonary disease (COPD - a group of lung disease that block airflow and make it difficult to breathe), and muscle weakness. Review of Resident 10's physician orders revealed an order for Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 mg (milligrams- unit of measure) Give 25 mg by mouth one time a day, with a start date of February 23, 2022, that was discontinued January 8, 2024. Further review of Resident 10's physician orders revealed an active order for Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 mg, Give 25 mg by mouth one time…

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, observation, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for two of three residents reviewed for pressure ulcers (Residents 1 and 135). Findings include: Review of facility policy, titled Dressings, Dry/Clean, with a last revised date of September 2013, revealed the following, in part: 6. Put on clean gloves. Loosen tape and remove soiled dressing; 7. Pull glove over dressing and discard into plastic or biohazard bag; 8. Wash and dry your hands thoroughly; 13. Put on clean gloves; 14. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage; 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, 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.

Based on review of clinical records and staff interviews, it was determined that the facility failed to provide interventions to prevent accidents for one out of six residents reviewed for accident hazards (Resident 48). Findings include: Review of Resident 48's clinical record revealed diagnoses that included hypertension (high blood pressure) and chronic respiratory failure (when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). Review of Resident 48's clinical record revealed the Resident had a fall off their bed on March 13, 2024, while receiving bathing assistance in bed by one nurse aid. Review of Resident 48's clinical record revealed that, after the fall on March 13, 2024, their comprehensive person-centered care plan was updated on March 18, 2024, with an intervention for bed mobility to include the resident requires assist of two to reposition and turn in bed. Further review of Resident 48's clinical record revealed an Activities of Daily Living Bed Mobility task, which included the support that was provided relating 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 facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen, two of two nourishment areas, and one of two medication storage areas. Findings include: Review of facility policy, titled General Food Preparation and Handling, last revised July 2023, read, in part, Food items will be prepared to consume maximum nutritive value, develop, and enhance flavor and free of injurious organisms and substances. The kitchen and equipment are clean. Foods are received, checked, and stored properly as soon as they are delivered. Leftovers must be dated, labeled, cooled, and stored. Review of facility policy, titled Food from Outside Sources, revised December 14, 2017, read, in part, Visitor/family member will label food and beverages with the resident's name, room number and date. Perishable foods with a 'use by' date which is 3 days from the date that it was brought into the facility. Observation of the dry storage area 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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to determine a resident's right to self-administer medications was clinically appropriate for one of one resident reviewed (Resident 3). Findings include: Review of facility policy, titled Self-Administration of Medications, with a last revised date of December 2016, revealed the following, in part: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so; 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident; 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) a. ability to read and understand labels, b. comprehension of the purpose and proper dosage and administration…

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

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 31 residents reviewed (Resident 96). Findings include: Review of Resident 96's clinical record revealed diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event with triggers that can bring back memories of the trauma accompanied by intense emotional and physical reactions). Review of Resident 96's current physician orders revealed an order for depakote (divalproex sodium-a medication used for the treatment of bipolar disorder) 25 milligrams administer three tablets daily at bedtime, dated June 4, 2024. Review of Resident 96's psychiatry consult dated June 14, 2024, revealed a…

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

Based on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for two of 10 residents reviewed for limited range of motion (Residents 10 and 84). Findings include: Review of Resident 10's clinical record revealed diagnoses that included left hand contracture (a permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult), chronic obstructive pulmonary disease (COPD - a group of lung disease that block airflow and make it difficult to breathe), and muscle weakness. Review of Resident 10's physician orders revealed an order for Left c grip hand splint. On with AM cares, off with PM cares, with a start date of January 25, 2024. Review of Resident 10's care plan revealed a focus area The resident has activities of daily living self-care performance deficits related to limited range of motion, last revised November 16, 2022, with an intervention 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 facility policy review, clinical record review, and staff interviews, it was determined the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, for one of seven residents reviewed (Resident 47), and failed to notify the physician of a significant weight loss for one of seven residents reviewed for nutritional status (Resident 81). Findings include: Review of facility policy, titled Weight Assessment and Intervention, dated March 2019, revealed The nursing staff will measure resident weight on admission, and then weekly for four weeks. If no weight concerns are noted at this point, weights will be measured monthly thereafter or as per Dietician or MD. Review of Resident 47's clinical record revealed diagnoses that included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using…

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 resident and staff interviews, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for two of four residents reviewed for respiratory care (Residents 57 and 397). Findings include: Review of facility policy, titled Oxygen Therapy, last reviewed April 2024, revealed that a physician must order the oxygen therapy. Review of Resident 57's clinical record revealed diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage, or spasms in a blood vessel) and hypertension (high blood pressure). During an observation of Resident 57 on July 8, 2024, at 11:13 AM, revealed Resident 57 was currently using oxygen. Further observation revealed the oxygen tubing was not dated. During an interview with Resident 57 on July 8, 2024, at 11:13 AM, revealed Resident 57 had been using oxygen for four days. Review of Resident 57's clinical record revealed a progress nursing note dated July 4, 2024, at 6:29 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, policy review, observations, and staff interview, it was determined that the facility failed to maintain infection control practices to prevent the spread of infection for one of nine residents reviewed for infection control (Resident 17). Findings include: Review of facility policy, titled Isolation - Multi Route Transmission-Based Precautions, last reviewed April 2024, revealed when a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and in front of the chart so that personnel and visitors are aware of the need for and type of precaution. Review of Resident 17's clinical record revealed diagnoses that included chronic atrial fibrillation (an irregular and often very rapid heart rhythm) and hypertension (high blood pressure). Further review of Resident 17's clinical record revealed a physician's order for contact precautions related to nasal MRSA (methicillin-resistance staphylococcus aureus), with an active date of May 24, 2024. Review of Resident 17's comprehensive person-centered…

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 documentation review, and resident and staff interviews, it was determined that the facility failed to provide care and services to ensure the residents' highest level of functioning and well-being for five of 10 residents reviewed (Resident 5, 7, 8, 9, and 10). Findings include: Review of Resident 5's clinical record revealed diagnoses that included hypertension (high blood pressure) and peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage, or spasm). Review of Resident 5's current physician orders reveal an order for the following: No blood pressure in left arm every shift for previous graft from left arm, with a start date of March 24, 2024. Review of Resident 5's clinical record Blood Pressure Summary documentation for the past 30 days (March 23, 2024, through April 18, 2024) revealed Resident 5 had their blood pressure taken in their left arm on the following dates and times: March 27, 2024 at 3:25 PM; April 2, 2024, at 9;17 PM, April 5, 2024, at 10:02 AM, April 9, 2024, at 10:23 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 policy review, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to report a resident elopement to the Department of Health as required for Residents 1 and 2. Findings Include: Review of facility policy, titled Elopement, with a revision date of June 2023, revealed, It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. Residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the premises of the facility without the knowledge and supervision of facility staff. Review of Employee 4's (Receptionist) statement, dated October 1, 2023, revealed, [Resident 1] + [Resident 2] were already sitting in the family room when I came in at 7:45. They sat till around 8:30 AM and their ride did not come. [Resident 1] got up and said I guess they aren't coming so, they went back to their room. At around 8:40 the car that picks them up came, didn't…

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 the facility assessment tool, as well as resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior on two of two nursing units (first and second floor nursing units). Findings include: Review of facility assessment tool, last reviewed August 17, 2023, revealed that maintenance staff complete routine rounds of buildings to ensure structural and operational stability and usefulness. Observation in Resident 33's room on September 11, 2023, at 10:02 AM, revealed a small hole in the ceiling above Resident 33's bed. A black substance was noted around the hole. Additionally, the paint on the wall near/above the head of Resident 33's bed appeared to be bubbling and peeling. During an immediate interview with Resident 33, he revealed that there had been a leak in that area. During a later interview with Resident 33 on September 14, 2023, at 9:37 AM, he revealed that he had told someone about the water concerns, but could not recall who. He also revealed that, during the time he had…

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

Based on clinical record review, resident and staff interview, and policy review, it was determined that the facility failed to ensure two of 29 residents reviewed were provided care and services regarding hygiene and bathing (Resident 75 and Resident 83). Findings include: Review of the facility's Activities of Daily Living (ADLs) Policy, last revised in March 2018, indicated that Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care). Review of Resident 75's clinical record revealed diagnoses that included unspecified dementia (mild memory disturbance due to known physiological condition) and chronic kidney disease (CKD - when your kidneys are moderately damaged and are not working as well as they should to filter waste from your blood). During the initial tour of the facility on September 11, 2023, at approximately 10:15 AM, an interview with 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.

Based on facility policy, review of the clinical record, observation, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 32 residents reviewed (Residents 9 and 59). Findings include: Review of facility policy, titled Medication Administration- General Guidelines, not dated, read, in part, medications are administered in accordance with written orders of the attending physician. Review of Resident 9's clinical record documented 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) and dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking). Review of Resident 9's physician orders included: Humalog (insulin Lispro, fast-acting insulin that helps control…

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

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the physician reviewed and responded to pharmacy review recommendations in a timely manner for five of five residents reviewed for unnecessary medications (Residents 9, 26, 50, 108, and 111). Findings Include: Review of facility policy, titled Medication Regimen Review (Monthly Report), last reviewed January 2023, revealed, The consultant pharmacist reviews the medication regimen of each resident at least monthly . Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's (active record) and reported to the Director of Nursing, and/or prescriber as appropriate. Recommendations are acted upon and documented by the facility staff and or the prescriber. Review of Resident 9's clinical record documented diagnoses that included gallstones (a small hard crystalline mass formed abnormally in the gall bladder), diabetes mellitus (the body's ability to produce 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility policy review, product labeling review, and staff interviews, it was determined that the facility failed to store food under sanitary conditions in the main facility kitchen and in two of two nursing unit nourishment refrigerators (first and second floor). Findings include: Review of facility policy, titled Storage Areas undated, revealed, Food should be dated as it is placed on the shelves. Date marking to indicate the date or day by which a ready-to-eat .All refrigerator units are always kept clean and in good working condition .Temperatures for refrigerators should be between 35-39 degrees F. Thermometers should be checked at least two times each day using the Refrigerator/ Freezer Temperature Log .Every refrigerator must be equipped with an internal thermometer .All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded. 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 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 three of 29 residents reviewed (Residents 50, 83, and 108). Findings include: Review of Resident 50's clinical record revealed diagnoses that included dementia, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of Resident 50's quarterly MDS assessment (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), dated June 14, 2023, revealed that in Section N, it was coded that a gradual dose reduction (GDR) of Resident 50's antipsychotic medication was last attempted on January 16, 2022. Review of Resident 50's clinical record revealed that Resident 50 last had a GDR of his antipsychotic…

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

Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for two of 29 residents reviewed (Resident 26 and 46). Findings include: Review of Resident 26's clinical record revealed diagnoses that included anxiety (intense, excessive, and persistent worry and fear about everyday situations) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident 26's current care plan revealed a care plan for the use of an antidepressant medication, citalopram (Celexa), and that a gradual dose reduction (GDR) was done of the citalopram on March 20, 2023. Review of Resident 26's clinical record, including physician orders, revealed that a GDR of the citalopram was done on March 20, 2023, to 5 mg (milligrams) once a day. Further review revealed that the citalopram was increased to 10 mg, once a day, on July 12, 2023. Review of Resident 26's care plan failed 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, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 29 residents reviewed (Resident 111). Findings Include: Review of Resident 111's clinical record revealed diagnoses that included dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident 111's nursing progress notes revealed a note, dated August 10, 2023, stating that an assessment was completed for use of a wanderguard bracelet (a monitoring device used to help ensure safety. Safety then depends upon the ensuring the alarm is activated and staff respond to the alarm when a patient or resident attempts to leave a safe area). The note further stated that Resident 111 has…

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

Based on review of clinical records, facility policy review, observations, and staff interviews, it was determined that the facility failed to provide restorative nursing care for range of motion devices for one of 29 residents reviewed (Resident 12). Findings include: Review of the facility's Resident Mobility and Range of Motion Policy, last revised in July 2017, indicated that residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Review of Resident 12's clinical record revealed diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) and chronic obstructive pulmonary disease (COPD - a group of disease that cause airflow blockage and breathing-related problems). Review of Resident 12's physician orders reveal an order on August 28, 2023, for a left resting hand splint, donned with morning cares, doffed with evening or as tolerated. Review of Resident 12's Occupational Therapy evaluation and plan of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, Centers for Disease Control guidelines, documents reviewed for implementation of a water management program, and staff interviews, it was determined the facility failed to implement their water management program for the prevention, detection, and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease [a serious type of pneumonia]). Findings Include: Review of facility policy, titled Legionella Water Management Program, revised September 2022, revealed The purpose of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. The policy further states, The water management program includes a plan for when control limits are not met and/or control measures are not effective. According to the Centers for Disease Control, The key to preventing Legionnaires' disease is to reduce the risk of Legionella growth and spread.…

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 the facility assessment tool as well as staff interviews, it was determined that the facility failed to ensure resident equipment was maintained in a safe operating condition on one of two nursing units (first floor nursing unit). Findings include: Review of facility assessment tool, last reviewed August 17, 2023, revealed that maintenance checks equipment during routine rounds; staff also assess equipment daily and report any items requiring repair or replacement. The assessment notes equipment includes such things as bath benches, shower chairs, bathroom safety bars, bathing tubs, sinks for residents and for staff, scales, bed scales, wheelchairs and associated positioning devices, bariatric beds, bariatric wheelchairs, lifts, lift slings, bed frames, mattresses, room and common space furniture, exercise equipment, therapy tables/equipment, walkers, canes, nightlights, steam table, oxygen tanks and tubing, dialysis chair. Observation with Employee 1 (Nursing Assistant) on September 11, 2023, at 12:31 PM, in the 300 hallway shower room revealed one…

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.