Monroeville Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical record, and staff and family interviews, it was determined that the facility failed to provide medically-related social services related to a resident transfer for one of three residents (Resident R11). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the facility policy, Social Services dated 11/1/24, indicated the facility provides medically-related social services to assure each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. The social worker / social services staff are responsible for helping residents with transitions of care services (for example, community placement options, home…

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

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly secured in one of three two of seven medication carts (First-floor medication cart for rooms 100-117) Findings include: Review of the facility policy Security of Medication Cart dated 11/1/24, indicated medication carts must be securely locked at all times when out of the nurse ' s view. During an observation on 2/8/24, at 2:18 p.m. of the the 100-117 medication cart was observed unlocked. The surveyor remained with the medication cart. At approximately 2:22 p.m. the surveyor opened and the medication cart drawers, and observed that the narcotic drawer was not secured. The surveyor reviewed the narcotic book, and narcotic cards. At 2:30 p.m. Registered Nurse Employee E4 was requested to confirm that the medication cart and the narcotic drawer were both unsecured. During an interview on 2/11/25, at approximately 3:00 p.m., the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make…

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, observations, and staff interview, it was determined that the facility failed to restrain hair and failed to perform handing washing to prevent the potential for cross contamination in the Kitchen. Findings include: Review of facility policy Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices reviewed 11/1/24, indicated food and nutritional services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Employees must wash their hands after handling soiled equipment or utensils. Hair nets or caps and/or beard restraints are worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens. Review of facility policy Policies and Procedures - Infection Prevention and Control reviewed 11/1/24, indicated the facility adopted infection prevention and control policies and procedures intended to help maintain a safe, sanitary, and comfortable environment…

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, staff interview, and observation, it was determined that the facility failed to provide an environment and care to promote dignity for each resident's quality of life for two of 16 sampled residents (Resident R47 and R36). Findings: Review of facility policy Dignity reviewed 11/1/24, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 -…

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

Based on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 17 of 17 residents (Residents R10, R16, R59, R105, R27, R36, R318, R500, R501, R502, R503, R504, R505, R506, R507, R508, and R509. Findings include: Review of the facility policy Call System dated 11/1/24, indicated calls for assistance are answered as soon as possible. During an observation on 12/16/24, at 2:40 p.m., the call light for Resident R59 was noted to be alarming. During an interview on 12/16/24, at 2:46 p.m. Resident R59 was asked why she needed help, and she responded that she was thirsty, and hadn't had a drink. During an observation on 12/16/24, at 2:51 p.m. Registered Nurse (RN) Employee was observed walking by Resident R59's room door and looking inside. When it appeared that she noted the State Agency (SA) in the room, stopped abruptly, looked up…

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

Based on review of facility policy and interview with residents and staff, it was determined that the facility failed to routinely offer or make available evening snacks as desired by nine of ten oriented residents (Residents R500, R501, R502, R503, R504, R505, R507, R508, and R509). Findings include: A review of facility policy Snacks (Between Meal and Bedtime), Serving dated 3/15/24. Indicates the purpose is to provide the resident with adequate nutrition. Facility staff report any problems or complaints made by the resident related to the snack. Report other information in accordance with the facility policy and professional standards of practice. Review of facility Snack Audits conducted during the months of August and September 2024 revealed only the volume and itemized list of snacks that were delivered to the nursing units. During a resident group interview on 12/17/24, at 10:30 a.m., nine of ten residents in attendance stated that they are not consistently offered a nourishing evening snack and there are not enough snacks for those who request them (Residents R500, R501,…

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 policies and clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for two of six residents (Resident R106 and R42). Findings include: Review of facility policy Charting and Documentation dated 3/15/2024, indicated Documentation of procedures and treatments shall include care-specific details and shall include at a minimum, whether the resident refused the procedure/treatment, signature, and title of individual documenting. Review of Resident R106's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R106's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/15/24, indicated diagnoses of pressure ulcer (PU) of sacral region, pressure ulcer of left hip (open wound with tissue damage), paraplegia (paralysis of the lower half of the body) and severe protein calorie malnutrition (not enough protein 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records and staff interview, it was determined that the facility failed to maintain hospice records for three out of five residents receiving hospice services (Resident R2, R72, and R92). Findings include: The facility Hospice Services Agreement policy dated 8/28/23, indicated that the facility will participate in hospice care as an approach for terminally ill residents. The facility must ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility. Review of facility policy Hospice Program reviewed 3/15/24 and 11/1/24, indicated hospice services are available ro residents at the end of life. Collaborating with hospice representatives and coordinating staff participation in the hospice care planning, communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions to ensure quality of care for…

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

Based on observations and resident and staff interviews it was determined that the facility failed to provide a clean and homelike environment on one of six nursing units (One East nursing unit) and for two of two residents (Residents R35 and R4). Findings include: During an observation on 12/20/24, at 11:00 a.m., of the One East nursing unit (Room of R4 and R35) the ceiling tile above the toilet revealed a large brown colored stain. During an interview on 12/20/24, at 11:05 a.m., Resident R35 stated The ceiling leaks down the wall and onto the floor. It's been going on for a long time. During an interview on 12/20/24 at 11:05 a.m., Resident R4 stated They changed the tile 3 times and it keeps happening. During an interview on 12/20/24 at 11:30 a.m., The Nursing Home Administrator confirmed the above findings and that the facility failed to provide a clean, comfortable homelike environment on One East nursing. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 201.29(k) Resident rights.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident record, investigation documents, and staff interview, it was determined that the facility failed to report an allegation of neglect for one of four sampled residents (Resident R166). Findings include: A review of the facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy dated 11/1/24, indicated that the facility will thoroughly investigate and report all allegations of abuse/neglect and will report to the Administrator and other officials as required. A review of Resident R166's admission record indicated the resident was admitted on [DATE], with diagnoses that included fracture of the cervical (neck) vertebrae, high blood pressure, and pain. Resident R166 discharged to home on [DATE]. A review of Resident R166's Minimum Data Set assessment (MDS -a periodic assessment of resident care needs) dated 11/12/24, indicated that the diagnoses were current upon review and the resident was alert, oriented, and cognitively intact. 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 review of facility policy and clinical records and staff interview, it was determined that the facility failed to make certain allegations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated and the results of all investigations are reported to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for one of four residents reviewed. (Resident R166). A review of the facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy dated 11/1/24, indicated that the facility will thoroughly investigate all allegations of abuse/neglect and will report to the Administrator and other officials as required. A review of Resident R166's admission record indicated the resident was admitted on [DATE], with diagnoses that included fracture 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 review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of four residents reviewed (Resident R106). Findings include: Review of facility policy, titled Oxygen Administration, with a review date of 3/15/24, purpose is to provide guidelines for safe oxygen administration. This includes verification of a physician order for oxygen or facility protocol, portable oxygen, regulator checking equipment and periodic assessment. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS 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 review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly stored and/or disposed of in one of two medication rooms (First Floor medication room). Findings include: Review of facility policy Medication Labeling and Storage dated 11/1/24, stated that if the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. During an observation of the First Floor medication room on 12/16/24, at 2:05 p.m. the following was observed: -(1) vacutainer with an expiration date of 5/31/23. -(2) vacutainers with an expiration date of 11/30/23. -(34) vacutainers with an expiration date of 2/29/24. -(6) vacutainers with an expiration date of 3/31/24. -(10) vacutainers with an expiration date of 4/30/24. -(6) vacutainers with an expiration date of 8/31/24. -(5) vacutainers with an expiration date of 9/30/24. -(1) I.V. start kit with an expiration date of 2/29/24. -(6) Bacterial…

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

Based on observations and staff interviews it was determined that the facility failed to provide a dignified dining experience to the residents during the lunch meal service on October 15, 2024, as required. Findings include: During an observation on 10/15/24, at 10:45 am it was revealed that the facility was utilizing disposable styrofoam bowls to serve the residents their dessert (cinnamon apples) for the lunch meal. During an interview on 11/15/24, at 10:57 am [NAME] Employee E1 confirmed that the facility was utilizing disposable styrofoam bowls to serve the residents their lunch dessert. During an interview on 10/15/24, at 11:15 am Food Service Director Employee E2 confirmed that the facility failed to maintain a supply of china or thermal serving bowls and was utilizing disposable styrofoam bowls to serve residents their dessert which failed to provide the resident with a dignified dining experience as required. PA Code: 201.29(k) Resident rights.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews it was determined that the facility failed to provide a method for resident visitors to easily access the facility to permit visitation of the resident during off hours (Saturday 10/26/24). as required. Findings include: During an observation on 10/26/24, at 9:18 a.m., the State Agency (SA) attempted to enter the facility. Upon entering the foyer area of the facility there was secured double doors preventing access to the facility. The SA attempted to gain access to the facility by activation of the intercom located on the right of the double doors. Upon activation a door bell sounded. No staff member responded to the door bell or the activated intercom. A notice displayed on the left side double door indicated that during off hours to call the facility's main telephone number that was provided on the posting. The surveyor placed a telephone call to this number. The telephone rang for approximately two minutes and then disconnected failing to be answered by staff or 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 a review of facility documents, an audit conducted by the State Ombudsman Office and staff interviews, it was determined that the facility failed to notify the State Ombudsman office of residents transfers and discharges for 42 of 42 months (3/21, 4/21, 5/21, 6/21, 7/21, 8/21, 9/21, 10/21, 11/21, 12/21, 1/22, 2/22, 3/22, 4/22, 5/22, 6/22, 7/22, 8/22, 9/22, 10/22, 11/22, 12/22, 1/23, 2/23, 3/23, 4/23, 5/23, 6/23, 7/23, 8/23, 9/23, 10/23, 11/23, 12/23, 1/24, 2/24, 3/24, 5/24, 6/24, 7/24, 8/24 and 9/24) as required. Finding include: A request to review facility documents on 10/15/24, of the facility's compliance in notifying the State Ombudsman Office revealed that the facility failed to provide documented evidence of notifying the State Ombudsman Office of residents transfers and discharges for the time period of 3/21, through 9/24. A review of an audit conducted on 8/1/24, by the State Ombudsman Office revealed that the facility failed to notify the State Ombudsman Office of resident transfers and discharges since 2/10/21. During an interview on 10/15/24, at 1:00 pm 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 observations and staff interviews it was determined that the facility failed to provide the residents with a homelike environment in room [ROOM NUMBER], the second floor Dining Room, the first floor resident lounge, and the second floor resident lounge. (room [ROOM NUMBER], Second floor Dining Room, First Floor resident lounge, and second floor resident lounge). Findings include: During an observation on 10/26/24, at 11:20 am it was revealed that the ceiling tile for the bathroom in room [ROOM NUMBER] contained a wet spot and brown markings indicating prior leaking water. The ceiling tile was located over the toilet. During an interview on 10/26/24, at 11:25 am Licensed Practical Nurse (LPN) Employee E5 confirmed that the ceiling tile contained brown marks indicating prior leaks and a current wet spot. A review of facility maintenance work orders revealed that a work order was submitted for the repair of the leak and replacement of ceiling tile in room [ROOM NUMBER] due to the resident voicing a concern…

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

Based on observations and staff interviews it was determined that the facility failed to maintain in proper working order equipment used for two of two methods for visitors to gain entrance to the facility during off hours. (Intercom system and Telephone system) Findings include: During an observation on 10/26/24, at 9:18 a. m., which was a Saturday morning, it was revealed that the intercom system used to notify staff of a visitor requesting access to the facility was not functioning properly. It was revealed that the intercom located at the first floor nursing unit had been removed from the wall which left exposed wire hanging from the wall and the nursing staff the inability to respond to an activated intercom and the visitor to gain access to the facility. During an observation on 10/26/24, at 9:20 am it was revealed that the facility's telephone number when unanswered by staff would disconnect and failed to transfer the call to another telephone extension which created the inability for the visitor to gain access to the facility. During an interview on 10/26/24, at 11:00 am 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 facility records and staff interviews it was determined that the facility failed to notify the resident's responsible party of two of two room changes (Resident R2) as required. Finding include: During a review of Resident R2's census record it was revealed that the resident had two room changes on 10/16/24. Census records indicated that Resident R2 was moved from room [ROOM NUMBER] bed A to room [ROOM NUMBER] bed A and then to room [ROOM NUMBER] bed A. A review of Resident R2's progress notes failed to provide evidence that the facility notified the resident's guardian/responsible party of the room changes. During an interview on 10/18/24, at 1:41 pm Resident R2's Guardian/Responsible Party RP1 confirmed that the facility failed to notify her of Resident R2's room changes. During an interview on 10/26/24, at 11:00 am information regarding the facility's failure to notify Resident R2's guardian/responsible party of the two room changes was addressed with the Nursing Home Administrator 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 a review of facility policies, documents and resident and staff interviews, it was determined that the facility failed to properly complete the grievance process for two of two resident allegations regarding the misappropriation of the resident's personal property. (Resident R1 and R3). Findings include: A review of facility Grievances/Concerns policy dated 9/10/24, indicated that the facility implements a grievance process by creating a grievance form, documents steps taken to investigate the grievance, complies a summary of the findings or conclusions, confirms a decision of either confirmed or unconfirmed, documents corrective action taken and dates when the resolution was issued. During a review of facility grievance documents on 10/15/24, it was revealed that the facility created a grievance form on 7/26/24, as the result of Resident R1's allegation that the maintenance department threw away her glasses. The grievance form provided no documentation of the findings of the facility's investigation, a summary of the findings, a decision of confirmed or unconfirmed…

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

Based on review of facility provided policies and documentation, clinical record review, and staff interviews, it was determined that the facility failed to protect residents from neglect of services for seven of 14 residents (R1, R2, R3, R4, R5, R6, and R7). Review of the facility policy Abuse Prohibition dated 7/24/24, previously reviewed 3/11/24, indicated the facility will prohibit abuse, mistreatment, neglect, misappropriation of property, and exploitation. The policy defined neglect as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility provided Wound Care Report dated 7/22/24, had handwritten notes on it. During an interview on 8/4/24, at 1:45 p.m. Wound Care Nurse Employee E1 stated that the report is the results of the wound rounds on 7/22/24; it was utilized as a reference on 7/29/24, and the handwritten information was the notes and changes from the wound…

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 policies and documents, clinical records, and staff interviews, it was determined that the facility failed to provide prescribed treatment and services related to the care of wounds for three of seven residents (Resident R1, R3, and R4). The facility policy Skin Integrity and Wound Management dated 7/24/24, previously reviewed 3/11/24, indicated the facility will provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing within the context of what matters most to all patients. Review of the facility provided Wound Care Report dated 7/22/24, had handwritten notes on it. During an interview on 8/4/24, at 1:45 p.m. Wound Care Nurse Employee E1 stated that the report is the results of the wound rounds on 7/22/24; it was utilized as a reference on 7/29/24, and the handwritten information was the notes and changes from the wound round of 7/29/24. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].…

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 and documents, clinical records, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for two of five residents (Resident R1 and R2). Findings include: Review of the United States Department of Health and Human Services, Agency for Healthcare Research & Quality's, Safety Program for Nursing Home: On-Time Pressure Ulcer Prevention dated May 2016, indicated that Pressure ulcers cause pain, disfigurement, and increased infection risk and are associated with longer hospital stays and increased morbidity and mortality. Three critical components in preventing pressure ulcers were listed: comprehensive skin assessments, standardized pressure ulcer risk assessments, and care planning and implementation to address areas of risk. Review of the National Library of Medicine, The Braden Scale for Predicting Pressure Sore Risk indicated the scale was developed to foster early identification of…

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

Based on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 13 of 15 residents (Residents R6, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, and R20). Findings Include: Review of the facility policy Staffing/Center Plan dated 7/24/24, previously reviewed 3/11/24, indicated centers will provide qualified and appropriate staffing levels to meet the needs of the patient population. The staffing plan will include all shifts, seven days per week. During an interview on 8/4/24, at 3:30 p.m. Resident R6, when asked if she felt the facility maintained sufficient staff, stated, If they show up. During an interview on 8/4/24, at 3:57 p.m. Resident R9, when asked if she felt the facility maintained sufficient staff, stated, No and further stated that she felt that she required more personal care than was provided. When asked if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy and documents, observation, and interviews, it was determined the facility failed to ensure the provision of a substantial evening snack to the residents when up to 16 hours elapsed from the supper meal to breakfast the next day, and failed to [NAME] resident group acceptance of a meal span of greater than 14 hours. Findings include: Review of the facility policy Meal Times and Delivery dated 7/24/24, previously reviewed 3/11/24, indicated Meals are provided at predictable time, three times daily. Meals are spaced not greater than 14 hours between the evening meal and breakfast meal. Review of facility's scheduled meal care delivery times revealed the following: Breakfast: First meal cart delivery at 7:00 a.m. - 7:15 a.m. (Rooms 100-119). Lunch: First meal cart delivery at 11:30 a.m. - 11:45 a.m. (Rooms 100-119). Dinner: First meal cart delivery at 4:45 p.m. - 5:00 p.m. (Rooms 100-119). During an observation on 8/4/24, at 3:53 p.m. the evening meal began to be distributed 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 staff interviews, it was determined that the facility failed to schedule ordered appointments for three of five residents (Resident R1, R2, and R3). Findings include: Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 2/3/24, included diagnoses of end stage renal disease (ESRD, an inability of the kidneys to filter the blood), atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of facility census information indicated Resident R1 was hospitalized from [DATE], through 1/23/24. Review of hospital discharge paperwork dated on 1/23/24, at 3:54 p.m. indicated that Resident R1 was to follow-up with a pulmonologist in four weeks (approximately 2/20/24). Review of Resident R1's clinical record failed…

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, invoices, account payable ledgers, vendor account receivable ledgers, and vendor and staff interviews, it was determined that the facility failed to pay invoices from their transportation vendor for six of six months (10/23, 11/23, 12/23, 1/24, 2/24, and 3/24) which caused the transportation vendor to terminate transport services to the residents. Finding include: 28 PA Code of the Pennsylvannia Department of Health, Long Term Care Facility Regulations, effective July 1, 2023, indicated that 201.14 subsection (g): A facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the resident's health and safety are jeopardized. A review of facility documents it was revealed that on 3/1/24, the facility was notified by a dialysis center that Resident R1's transportation to return to the facility was cancelled due to non payment. A review on 3/11/24, of the transportation vendor's account receivable ledger revealed that the facility had unpaid past due…

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, facility provided information, clinical record, observation and staff interviews it was determined that the facility failed to consistently maintain resident safety during a transfer resulting in a laceration of the left leg for one of three residents (Resident R1), Findings include: Review of the facility policy Accidents/Incidents, last reviewed on 2/1/24, with a previous review date of 12/1/23, indicated that center staff will report, review and investigate all accidents/incidents. The nurse assessing the resident will document the accident/incident the patient's chart and include all pertinent information. The Director of Nursing(DON) and Administrator will review all the information for completion and report the incident. The root cause should be determined through a thorough investigation. Review of the facility Safe Resident Handling Program last reviewed on 2/1/24, with a previous review date of 12/1/23, indicated that all residents are evaluated on admission by 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 observations and staff interview, it was determined the facility failed to display the contact information (name, address, email address, and phone number) for the local State Survey Agency and a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation for six of six resident information areas (first floor elevator area, internet cafe, 100 unit, second floor elevator area, resident lounge, and 200 unit). Findings include: During an observation on 1/9/24, at 11:20 a.m. contact information was not displayed for the State Survey Agency, and there was no information that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation on the first floor elevator area. During an observation on 1/9/24, at 11:23 a.m. contact information was not displayed for the State Survey Agency, and there was no information that the resident may file a complaint with the State Survey Agency concerning any…

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

Based on a review of facility policy, observations, and staff interview, it was determined the facility failed to identify the current grievance official who is responsible for overseeing the grievance process necessary to take immediate action to prevent further potential violations of any resident right at six of six posting areas (first floor elevator area, internet cafe, 100 unit, second floor elevator area, second floor resident lounge, and 200 unit.) Findings include: Review of facility policy titled Grievance Concerns last reviewed 9/1/23, informed a description of the procedure for voicing grievances/concerns will be on each unit in a prominent location and must include the contact information of the grievance official with whom a grievance can be filed, that is, their name, business address (mailing and email) and business phone number. During an observation on 1/9/24, at 11:20 a.m. the contact information for the current grievance official was not posted at the first floor elevator area. During an observation on 1/9/24, at 11:23 a.m. the contact information for the current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, resident record reviews, and staff interviews, it was determined the facility failed to provide fundamental care and treatment in accordance with professional standards of practice to ensure each resident will meet the highest practicable level of physical, mental, and psychological well-being by failing to follow physician orders for nutritional services for one of two residents (Resident R53), and failed to document wound care for four of seven residents with pressure ulcers (Residents R55, R71, R103 and R217) and failed to follow a physicians order to send one of four residents to a follow up appointment (Resident R71). Findings include: Review of facility policy titled Nutrition/Hydration Care and Services last reviewed 9/1/23, informed staff will provide nutritional and hydration care services for each patient consistent with the patient's comprehensive care assessment and will provide a therapeutic diet that accounts for the patient's clinical conditions 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and resident and staff interviews, it was determined that the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents (Resident R26). Review of the clinical record indicated Resident R26 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 11/9/23 included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of Section J: Health Conditions revealed resident R26 is on a scheduled pain medication regimen. Review of the facility diagnosis list included an open wound of the abdominal wall and polyosteoarthritis (condition when five or more joints are affected…

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, resident records and staff interviews, it was determined the facility failed to maintain complete and accurate dialysis communication forms and failed to maintain ongoing communication with the dialysis center (an outpatient treatment center for those with chronic kidney failure) for three of six residents. (Residents R20, R62, and R600). Findings include: Review of facility policy titled Dialysis: Hemodialysis (HD) - Communication and Documentation, last reviewed on 9/1/23, informed staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis (a machine that filters waste from the blood when the kidneys are no longer able) treatments received at a certified dialysis facility. Prior to leaving the Center for HD, a licensed nurse will complete the top portion of the Hemodialysis Communication Record ot the state required form and send with the resident 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 the clinical record and staff interview, it was determined that the facility failed to provide documentation that it acted on the pharmacy recommendations two of five residents (Resident R26 and R92). Findings include: Review of Resident R26's and Resident R92's clinical records indicated Pharmacist Medication Regimen Reviews completed at least monthly. Review of Resident R26's reviews completed on 8/9/23, 9/11/23, 10/26/23, 11/5/23, 11/27/23, and 12/28/23, all indicated Comment/Recommendation noted - see report. Review of Resident R92's reviews completed on 9/11/23, 10/26/23, 11/27/23, and 12/28/23, all indicated Comment/Recommendation noted - see report. On 1/10/24, the pharmacist reports were requested from the facility. The recommendations were not received. During an interview on 1/12/24, at 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide documentation that it acted on the pharmacy recommendations two of five residents. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, water testing logs and staff interview, it was determined that the facility failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia) for ten of twelve months(April 2023 through January 2024). Findings include: The facility has no Water Management Program based on framework outlined in ASHRAE and CDC Standards identified as per the Maintenance Director Employee E3 and confirmed with the Nursing Home Administrator to minimize risk for Legionella associated with the building water systems at Monroeville Skilled Nursing and Rehabilitation Center. During an interview on 1/11/24, at 1:15 p.m., Maintenance Director Employee E3 and the Nursing Home Administrator confirmed that the facility did not implement and effective water management program for the prevention and control of water-borne contaminants, such as Legionella since 2022. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa.…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on resident protection from abuse and neglect for 13 of 15 staff members (Employees E7, E8, E9, E10, E12, E13, E14, E15, E16, E17, E18, E19, and E20). Findings include: Review of the Facility Assessment dated 11/28/23, indicated that all employees will receive training and education on abuse protection during general orientation. Review of the policy Inservice Training dated 9/1/23, indicated the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory inservices must be completed annually as a condition of employment. Review of personnel files for newly hired Employees E7, E8, E9, and E10 revealed the following staff members did not have documented training on resident protection from abuse and neglect. Activities Employee E7 had a hire date of 10/2/23, failed to have documentation of training in resident protection from abuse and neglect completed upon hire. Dietary Employee E8 had a hire date of…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on infection control procedures for six of ten staff members (Employees E12, E13, E14, E17, E18, and E19). Findings include: Review of the policy Inservice Training dated 9/1/23, indicated the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory inservices must be completed annually as a condition of employment. Review of facility provided documents and training record for Employees E12, E13, E14, E17, E18, and E19 revealed the following staff members did not have documented training on infection control procedures . Nurse Aide (NA) Employee E12 had a hire date of 9/27/07, failed to have infection control procedures in-service education between 9/27/22, and 9/27/23. NA Employee E13 had a hire date of 8/19/21, failed to have infection control procedures in-service education between 8/19/22, and 8/19/23. NA Employee E14 had a hire date of 1/3/19, failed to have infection control procedures in-service…

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

Based on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for four of five nurse aides (Employees E12, E13, E14, and E15). Finding include: Review of the Facility Assessment dated 11/28/23, indicated nursing assistants are required to complete 12 hours of in-service training per year, including areas of weakness as identified in performance evaluations. Review of the policy Inservice Training dated 9/1/23, indicated the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory inservices must be completed annually as a condition of employment. Review of Nurse Aide (NA) Employees E12, E13, E14, and E15 education records with hire date greater than 12 months revealed the following: Nurse Aide (NA) Employee E12 had a hire date of 9/27/07, with 1.04 hours in-service education between 9/27/22, and 9/27/23. NA Employee E13 had a hire date of…

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

Based on observations and staff interviews it was determined that the facility failed to provide a clean and homelike environment in one of two shower rooms(Second floor) and for two of four residents( Resident R83 and R84). Findings include: During an observation on 1/9/24, at 11:27 a.m., of the second floor bathroom located in the shower room, the toilet had hard stool and paper towels lying in toilet, the toilet was partially blocked with three shower chairs and other equipment. During an interview on 1/9/24, at 11:27 a.m., the Maintenance Director Employee E3 confirmed that the facility failed to provide a clean comfortable homelike environment for the residents of the second floor. During an observation on 1/10/24, at 8:23 a.m., of Residents R83 and R84 room, indicated soiled floor with debris under beds and black spots on the floor as well as food debris and personal belongings, the bathroom trash can was overflowing and the residents overbed tables were soiled with debris. During an interview on 1/10/24, at 8:25 a.m., Licensed Practical Nurse(LPN) Employee E4 confirmed 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 a observation and staff interview, it was determined that the facility failed to provide a safe environment for residents in one of two resident lounges/activity areas (second-floor activity room). Findings include: During an observation on 1/10/24, at 5:52 p.m. two large bread knives, three steak knives, five paring knives, and one utility knife were observed in an unsecured drawer in the activity room. During an interview on 1/10/24, at 5:55 p.m. Activities Director Employee E1 confirmed that the second-floor activities room is available for resident use when staff members are not present, and confirmed that the presence of eleven knives in an unlocked, waist-height drawer posed a safety risk to the residents. During an interview on 1/12/23, at approximately 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide a safe environment for residents in one of two resident lounges/activity areas. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.20(a)(b) Staff development. 28 Pa. Code 201.29(a)(c)(d) Resident rights.

Based on review of facility documents and staff interview, it was determined that the facility failed to make certain that all of the required members were in attendance at least quarterly at the Quality Assurance Process Improvement (QAPI) Committee meetings for two of four quarters, and failed to provide sign in sheet for QAPI Committee meetings for four of five meetings held (April 2023, May 2023, August 2023 and October 2023). Findings include: Review of the CFR (Code of Federal Regulations) §483.75(g) Quality assessment and assurance. §483.75(g) Quality assessment and assurance. §483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (iv) The infection Preventionist. (i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI…

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 personnel files and staff interviews it was determined that the facility failed to employ a qualified full time Food Service Director for four of four months. (9/23, 10/23, 11/23, and 12/23), Findings include: During an interview on 12/11/23, at 8:55 am Registered Dietitian Employee E1 confirmed that the facility failed to employ a full time Food Service Director. She stated that she was uncertain how long the prior Food Service Director resigned the position but she felt it was a couple months. During a review of Food Service Director (FSD) Employee E4's personnel file it was revealed that FSD Employee E4 resigned the position without notice on 9/22/23. During an interview on 12/11/23, at 9:00 am the Nursing Home Administrator confirmed that the facility failed to employ a full time Food Service Director since the resignation of FSD Employee E4. PA Code: 211.6(c)(d) Dietary Services.

Based on a review of facility policies, three week Fall/ Winter cycle menu, menu postings and staff interviews it was determined that the facility failed to properly plan and post a cycle menu with alternative selections of equal nutrient value and to have a Registered Dietitian review and approve the three week cycle menu prior to implementation for three of three weeks of the cycle menu (Week one, Week two, and Week three of the Fall/ Winter cycle menu). Findings include: During an observation on 12/11/23 at 10:00 am of the facility's menu selection displayed in the first floor dining room it was determined that the facility failed to list an alternate menu selection of equal nutrient value. During a review of the facility's three week Fall/ Winter cycle menu it was revelaed that the menu failed to list an alternate menu selection of equal nutrient value for each meal of the cycle and failed to provide documented evidence that the facility's Registered Dietitian reviewed and approved the menus prior to implementation. During an interview on 12/11/23 at 12:05 pm Registered…

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, observations and staff interviews it was determined that the facility failed to maintain equipment vital to the operation of the facility in proper work condition in the Main Kitchen and Laundry. (Main Kitchen, Laundry) Findings include: During an observation on 12/11/23, at 12:05 pm of the lunch meal food temperature audit it was determined that the point of service food temperatures failed to meet the facility's guidelines for palatable food. During this observation Registered Dietitian Employee E1 confirmed that the facility's induction heater for heating the thermal bases utilized to maintain point of service food temperatures was non operational. A review of facility documents revealed that on 10/15/23, Food Service Regional Manager Employee E8 emailed the corporate office regarding the heat induction system being non operational effective 10/14/23. During an interview of 12/11/23, at 1:00 pm the Nursing Home Administrator confirmed that the facility was aware of the Induction Heater being non operational. He further confirmed that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 17 of 25 residents (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17). Findings Include: Review of the facility policy Staffing/Center Plan dated 8/7/23, indicated centers will provide qualified and appropriate staffing levels to meet the needs of the patient population. The staffing plan will include all shifts, seven days per week. During an interview on 10/28/23, at 1:02 p.m. Resident R1, when asked if call lights took a long time to be answered, stated, I have to wait a lot. During an interview on 10/28/23, at 1:02 p.m. Resident R2, when asked if he felt the facility maintained sufficient staff, he stated loudly, No. Resident R2 stated that he has been…

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 documents, and resident and staff interviews, it was determined that the facility failed to provide appropriate assistance to prevent avoidable falls for one of five residents reviewed (Resident R5). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R5 was admitted to the facility on 4//26/21. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 10/12/23, revealed diagnoses of osteoarthritis (degeneration of the joint causing pain and stiffness), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and muscle weakness. 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 facility policy, resident clinical record, resident interview and staff interview, it was determined the facility failed to administer parenteral fluids consistent with professional standards of practice required to meet the nutritional needs of residents for one of two residents (Resident R1). Findings include: Review of facility policy titled Parenteral Nutrition Support, last reviewed 5/1/23, informed patients/residents whose nutritional needs cannot be met via oral or tube feeding are nourished via Total Parenteral Nutrition (TPN). TPN is indicated for a resident who has established malnutrition (or is at significant risk of developing malnutrition), and has a gastrointestinal tract that is either non-functional or cannot be accessed. Review of Resident R1's clinical record indicated the resident was admitted to the facility on [DATE]. Diagnoses included anemia (blood produces lower then normal red blood cells), dehydration, acute kidney failure (kidneys suddenly become unable to filter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, observations, and staff interviews it was determined the facility failed to meet the daily nutritional and special dietary needs for two of two residents (Resident R2 and Resident R3). Findings include: Review of facility policy titled Supplementation last reviewed 5/1/23, informed the purpose is to provide medical food supplements to a resident whose meal intake is inconsistent or inadequate and only when ordered by a physician/advanced practice provider. Review of Resident R2's record indicated the resident was admitted to the facility on [DATE]. Diagnoses included diabetes, anemia (low red blood cells reducing oxygen to the organs), chronic obstructive pulmonary disease (constricted airways cause difficulty or discomfort in breathing), atrial fibrillation (irregular fast heartbeat), right hip fracture, and congestive heart failure (the heart doesn't pump blood effectively). Review of Resident R2's current physician orders dated 8/30/23, included a House Shake (nutritional…

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.