Montgomeryville Skilled Nursing And Rehabilitati

Based on clinical record review and observation, it was determined that the facility failed to accommodate resident needs by providing access to the call bell system for one of 34 sampled residents. (Resident 124) Findings include: Clinical record review revealed that Resident 124 had diagnoses that included depression. Review of the care plan revealed that the resident was at risk for falls and that staff was to reinforce the need to call for assistance. On May 19, 2024, from 9:52 a.m. through 1:16 p.m., the resident was observed lying in bed. There was no call bell plugged into the system for the resident's side of the room. On May 20, 2023, at 9:53 a.m., the resident was observed lying in bed. There was no call bell plugged into the system for the resident's use. On May 21, 2024, from 9:12 a.m. through 12:08 p.m., the resident was observed lying in bed. The call bell was on the nightstand, out of reach. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, it was determined that the facility failed to complete a comprehensive assessment for two of 34 sampled residents. (Residents 106, 107) Findings include: Clinical record review revealed that Resident 106 was transferred to and admitted to the hospital for a change in condition on April 14, 2024. There was no Minimum Data Set (MDS) assessment completed to reflect that the resident was discharged from the facility. In an interview on May 22, 2024, at 9:57 a.m., the Director of Nursing confirmed an MDS assessment had not been completed for Resident 106's discharge to the hospital. Clinical record review revealed that on March 29, 2024, the physician ordered hospice services for Resident 107. Review of a recent doctor's note dated May 1, 2024, revealed that the resident continued to be on hospice services. There was no MDS assessment completed to reflect the significant change in his status. In an interview on May 22, 2024, at 9:50 a.m., the Director of Nursing confirmed that a significant change MDS had not been completed for Resident 107 when 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs for three of 34 sampled residents. (Residents 121, 124, 296) Findings include: Clinical record review revealed that Resident 121 was readmitted to the facility on [DATE], and had diagnoses that included acute pulmonary edema and congestive heart failure. There was no care plan developed to address Resident 121's needs. Clinical record review revealed that Resident 124 was admitted to the facility on [DATE], and had diagnoses that included bacteremia and benign prostatic hyperplasia (urinary condition). On April 25, 2024, the physician ordered for Resident 124 to have an indwelling urinary catheter. There was no evidence that interventions to address Resident 124's urinary status and catheter were included in the current care plan. Clinical record review revealed that Resident 296 was admitted to the facility on [DATE], and had diagnoses that included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to follow physician orders for three of 34 sampled residents. (Residents 107, 115, 296) Findings include: Clinical record review revealed that Resident 107 had diagnoses that included a history of sepsis (infection of the blood) and Alzheimer's disease. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had been on an antibiotic medication in the last seven days and that he had a primary medical condition of sepsis of an unspecified organism. On March 18, 2024, a physician ordered for staff to administer an antibiotic medication (amoxicillin) twice a day for seven days for a total of 14 doses of the medication. Review of the March 2024 Medication Administration Record (MAR), revealed that staff had not administered the first dose of the antibiotic on March 18, 2024. Review of a nursing note dated March 18, 2024, revealed that the antibiotic was not administered because it had not 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 clinical record review, observation, and staff interview, it was determined that the facility failed to provide services and treatment to prevent further limitations in range of motion for one of five sampled residents who had limitations in range of motion. (Resident 41) Findings include: Clinical record review revealed that Resident 41 had a diagnosis of a stroke with hemiplegia, (paralysis), of the non-dominant left side. The Minimum Data Set assessment dated [DATE], indicated that the resident had some memory impairment and had limitations in range of motion on one side of the lower and upper extremities. A review of the care plan revealed that the resident had an activites of daily living deficit due to physician limitations. There was a current intervention for staff to apply a left resting hand splint in the morning and to remove it at night. In addition, there was a current physician order since March 8, 2024, for staff to apply the left resting hand splint every day to prevent contractures.…

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 provide adequate supervision and interventions to prevent accidents for two of five residents at risk for accidents. (Residents 2, 100). Findings include: Clinical record review revealed that Resident 2 had diagnoses that included traumatic brain injury and history of falls. Review of Resident 2's care plan revealed he was at risk for falls with interventions for staff to provide music or YouTube videos and to provide a laptop to watch baseball games. On May 19, 2024, at 9:15 a.m. through 10:45 a.m., and 12:08 p.m. through 12:45 p.m., Resident 2 was observed in his wheelchair in the hallway with no music, videos, or laptop. On May 20, 2024, at 10:05 a.m. through 12:35 p.m., Resident 2 was again observed in his wheelchair in the hallway with no music, videos, or laptop. In an interview on May 22, 2024, at 12:13 p.m., the Director of Nursing confirmed that staff should have provided music, YouTube videos, or a laptop to watch baseball games to Resident 2.…

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

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to provide services consistent with professional standards of practice for one of two residents who received dialysis. (Resident 39) Findings include: A review of the facility policy entitled, Dialysis: Hemodialysis (HD) Provided by a Certified Dialysis Facility, last reviewed February 1, 2024, revealed that professional standards of practice included ongoing communication and collaboration with the dialysis facility regarding HD care and services. The care of the patient who received HD reflected ongoing communication, coordination, and collaboration between the center and dialysis staff. Communication included medication administration and changes, advanced directive and code status, and changes to functional status or falls. Clinical record review revealed that Resident 39 had diagnoses that included hypertension, heart failure, and end stage renal disease. Review of the resident's dialysis communication forms revealed that the pre-treatment report, which included code…

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

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement a individualized, person-centered plan to render trauma informed care to a resident with a diagnosis of post-traumatic stress disorder (PTSD) for one of 34 sampled residents. (Resident 84) Findings include: Clinical record review revealed that Resident 84 had diagnoses that included bipolar disorder, depression, anxiety, aphasia (impaired ability to understand or form language), and PTSD. Further review of the resident's clinical record revealed that there were no resident specific interventions to meet the resident's needs for minimizing triggers or preventing re-traumatization. In an interview on May 22, 2024, at 11:51 a.m., the Director of Nursing confirmed the resident had a diagnoses of PTSD, and no individualized care plan was developed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that pharmacy recommendations were acted upon by the physician for one of 34 sampled residents. (Resident 111) Findings include: A review of the facility policy entitled, Medication Regimen Review, last reviewed February 1, 2024, revealed that the facility was to ensure that the attending physician, Medical Director, and Director of Nursing (DON) were provided with copies of the medication regimen reviews. The attending physician should document in the resident's record that an irregularity was reviewed and what, if any, action had been taken to address it. The attending physician should have addressed the consultant pharmacist's recommendation on their next scheduled visit to the facility to assess the resident, and no later than 60 days. Clinical record review revealed that Resident 111 had diagnoses that included dementia and insomnia. On October 31, 2023, the physician ordered for staff to administer melatonin (a hormone that assisted with sleep)…

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, review of facility documentation, observation, and resident interview, it was determined that the facility failed to ensure that a resident's preference at meal times had been accommodated for two of 34 sampled residents. (Residents 49, 126) Findings include: Clinical record review revealed that Resident 49 had diagnoses that included dysphagia (difficulty swallowing) and atrial fibrillation. Reivew of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had no cognitive impairment. Review of Resident 49's care plan revealed she had a nutritional risk with an intervention for staff to honor food preferences. In an interview on May 19, 2024, at 12:43 p.m., the resident stated that she often didn't receive the food that she ordered. According to the resident's meal selection sheet (a document completed weekly by the resident to select food choices) she requested spinach, egg, and cheese casserole for lunch that day. When her lunch tray was observed at 12:50…

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, observation, and resident and staff interview, it was determined that the facility failed to ensure that a therapeutic diet was provided as recommended by a registered dietician to one of 14 sampled residents who were at risk for weight loss. (Resident 43) Findings include: Clinical record review revealed that Resident 43 had diagnoses that included rhabdomyolysis (breakdown of muscle tissue), diabetes, and anemia. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented, had weight loss, was not on a prescribed weight loss program, and was on a therapeutic diet. Review of a registered dietician's note dated March 7, 2024, revealed that the resident had a weight loss, had a good appetite, and that the resident stated he feels that breakfast portions can sometimes be too small. At that time, the dietician documented that the resident was to be provided with double portions at meals. Review of the facility master diet guide sheet revealed…

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 documentation review, observation, and family, resident, and staff interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times, in a timely manner, and in accordance with the residents' needs on one of three the nursing units. (Second floor nursing unit) Findings include: Review of the facility meal times schedule revealed that lunch was to arrive on the nursing units between 11:30 a.m. and 1:00 p.m On May 19, 2024, at 12:45 p.m., confidential staff interviews on the second floor nursing unit revealed that the lunch was being served very late today and had been served late on other occasions. In a confidential interview on May 19, 2024, at 1:09 p.m., a family member of a resident on the second floor stated that meals were frequently served late. Observation at that time revealed that the resident of this family member did not receive lunch until 1:15 p.m., 15 minutes after the latest scheduled time for the meals to arrive on the nursing units. In an interview on May 19, 2024, at 1:00 p.m., Residents 32 and 34…

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, facility documentation review, and staff interview, it was determined that the facility failed to ensure that safety interventions were implemented during a transfer from bed to chair for one of four sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included brain bleed, stroke, and bipolar disorder. The Minimum Data Set assessment dated [DATE], revealed that the resident was non-ambulatory, dependent upon staff for care, and required the assistance of two staff with the use of a lift for transfers out of bed. The resident's care plan dated March 23, 2024, directed staff to provided full assistance of two staff members with the use of a lift for all transfers out of bed. Nursing documentation dated March 28, 2024, at 11:00 a.m., indicated that the resident was heard yelling for staff while seated in her wheelchair in her room. The resident stated that her head got bumped…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to implement an effective discharge planning process to prepare residents for discharge for one of three sampled residents. (Resident 1) Findings include: Review of facility policy entitled, Discharge with Medications, dated February 1, 2024, revealed that staff was to review the medication orders and directions for use with the resident before the resident's discharge to home with the medications and to document this review in the resident's medical record. Review of facility policy entitled, Discharge Planning Process, dated February 1, 2024, revealed that staff was to provide a copy of the Discharge Transition Plan and Discharge Packet to all residents discharging to home. Clinical record review revealed that Resident 1 had diagnoses that included diabetes, end stage renal disease, hypertension, atrial fibrillation, and pain. Review of the Minimum Data Set assessment dated [DATE], revealed the…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of three sampled residents. (Resident 1) Findings include: Clinical record reivew revealed that Resident 1 had diagnoses that included diabetes, anemia, sepsis and chronic pressure ulcers. On January 3, 2024, a physican directed staff to schedule a cardiology consultation for the resident. Clinical record review revealed that as of February 12, 2024, the consultation was not scheduled. In an interview of February 12, 2024, at 12:05 p.m., the Director of Nursing confirmed that the consultation was not scheduled as ordered by the physician. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to notify the resident's responsible party of a change in treatment for one of six sampled residents. (Resident 1) Findings include: Review of the facility's policy entitled, Change in Condition: Notification of, dated February 2023, revealed that the Center must immediately inform the resident's representative when there was a need to alter treatment significantly such as a need to discontinue, change, or commence a treatment. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation, seizures, and diabetes. The Minimum Data Set assessment dated [DATE], revealed the resident had memory impairment. On January 4, 2024, based on electrocardiogram results, the physician directed staff to hold the medications, amiodarone and Toprol-XL until the resident was seen by the cardiologist for a scheduled consultation on March 24, 2024.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to adequately monitor and assess significant weight loss for one of three sampled residents at risk for weight loss. (Residents 2) Findings Include: Clinical record review revealed that Resident 2 had diagnoses that included anemia, diabetes mellitus, and [NAME] Syndrome (a genetic disorder that causes physical, mental and behavioral problems, including a constant sense of hunger). Review of a wound assessment dated [DATE], revealed that the resident had multiple pressure wounds. Review of the care plan revealed a potential for nutrition problems. On October 20, 2023, the resident weighed 161.2 pounds (lbs.). On November 17, 2023, the resident weighed 138.2 lbs., which reflected a 14.2 percent significant weight loss. On December 1, 2023, the resident weighed 126.4 lbs., which reflected a further significant weight loss of 8.5 percent. There was no evidence that the dietitian addressed the resident's continued weight…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the responsible party was notified of a change in condition in medical status and a fall for one of four sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included acute and chronic respiratory failure, diabetes and atrial fibrillation. On October 19, 2023, a physician noted that the resident had a urinary tract infection (UTI) and ordered an antibiotic medication to treat the UTI. There was no documented evidence that the responsible party was notified of this change in medical condition. In addition, review of an incident report dated October 21, 2023, revealed that the resident had experienced a fall and had been found on the floor, lying on her back in her room. Review of nursing documentation dated October 22, 2023, at 12:00 a.m., revealed that nursing staff was to make the day shift nurse aware of the fall and to notify the responsible party of the fall in the morning. There was no documented evidence…

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 interview, it was determined that the facility failed to ensure that physician ordered medications were obtained from the pharmacy for one of four sampled residents. ( Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE]. with diagnoses that included metastatic cancer and intractable nausea and vomiting. On May 21, 2023 the physician ordered staff to administer a medication to lessen anxiety (Ativan) every twelve hours sublingually (under the tongue). Review of nursing documentation revealed that as of May 23, 2023, the medication had not yet been delivered by the pharmacy. In an interview on August 9, 2023, at 11:00 a.m. , the Director of Nursing confirmed that the medication was not provided timely by the pharmacy. 28 Pa. Code 211.19(a)(d) Pharmacy services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained on three of three nursing units. (Rehabilitation, First and Second floor) Findings include: Observations on the rehabilitation nursing unit on May 30, 2023, at 11:26 a.m., through May 31, 2023, at 10:40 a.m., revealed the following: In room [ROOM NUMBER], there were heavily marred walls and peeling wallpaper by the door. In room [ROOM NUMBER], the bathroom floor was heavily stained, the baseboard behind the toilet was missing, the toilet was loose, and the bathroom had a strong pervasive urine odor. In room [ROOM NUMBER], there was a brown stained ceiling tile over the television. In rooms 14, 15, 23, 27, and 30 the walls were heavily marred and scratched. During tour of the first floor nursing unit on May 30, 2023, at 10:00 a.m. through May 31, 2023, at 1:30 p.m. the following observations were made: In room [ROOM NUMBER], a dried brown substance was observed around the base…

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 interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for six of 25 sampled residents. (Residents 50, 65, 97, 114, 115, 116) Findings include:. Clinical record review revealed that Resident 50 had a diagnosis of end-stage kidney disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], identified that the resident received hospice services and a care plan should have been developed to address the hospice services. Review of the care plan revealed that the facility did not develop interventions to address hospice care. Clinical record review revealed that Resident 65 had a diagnosis that included dementia. Review of the MDS assessment dated [DATE], identified that the resident received hospice services and a care plan should have been included on the resident's care plan. Review of the care plan revealed that the facility did not develop…

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

Based on clinical record review and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for three of 25 sampled residents. (Residents 41, 97, 115) Findings include: Clinical record review revealed that Resident 41 had diagnoses that included osteoarthritis and spinal stenosis. There was a physician's order, dated May 1, 2023, for staff to provide the resident with narcotic pain medication (oxycodone) every six hours as needed for pain. Review of the May 2023, medication administration records (MARs) and nursing notes revealed there was a lack of documentation to support that the resident was offered non-pharmacological interventions prior to or in conjunction with the administration of the as needed pain medication on 20 of 39 occurrences. On May 23, 2023, the physician's order changed for staff to administer the as needed narcotic pain medication (oxycodone) every four hours as needed for pain. Review of the May 2023, MARs and…

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

Based on review of facility policy and observation, it was determined that the facility failed to store food under sanitary conditions on the nursing units. (Rehabilitation and Second floor nursing units) Findings include: Review of facility policy entitled, Food Brought in for Patients/Residents, last reviewed February 14, 2023, revealed that all items would be labeled and dated with the resident's name and date that the food was brought in and that after three days would be discarded. Observation of the refrigerator on the rehabilitation nursing unit on May 31, 2023, at 12:59 p.m. revealed a container of takeout food and lunch bags that were brought into the facility and were not labeled or dated. There were numerous dried liquid stains throughout the refrigerator. Observation of the refrigerator on the second floor nursing unit on May 31, 2023, at 11:45 a.m., revealed a container of mixed vegetables, two unidentified food items wrapped in foil, and a container of salad that were brought into the facility and were not labeled or dated. The shelves of the refrigerator had numerous…

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 interview, it was determined that the facility failed to provide services to enhance each resident's quality of life by offering showers as scheduled to two of 25 sampled residents. (Residents 119, 384) Findings include: Clinical record review revealed that Resident 119 had diagnoses that included right arm fracture and depression. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was oriented and required staff assistance for bathing. The resident was to receive a shower twice per week and as needed. During an interview on May 31, 2023, at 11:30 a.m., the resident reported that she preferred to take a shower twice a week and was not offered the opportunity to do so. Review of documentation in the clinical record revealed that the resident was not offered a shower four of nine scheduled times in the past 30 days. There was a lack of documentation to support that Resident 119 was consistently provided the opportunity to have a shower as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interview, it was determined that the facility failed to consistently provide treatments for a pressure ulcer for one of 25 sampled residents. (Resident 116) Findings include: Clinical record review revealed that Resident 116 was admitted to the facility on [DATE], with diagnoses that included a pressure ulcer and anemia. On February 2, 2023, a nurse noted that the resident had a Stage II pressure ulcer to her coccyx and the physician ordered for staff to provide wound care and change the dressing daily. Review of the current care plan revealed that the resident had a pressure ulcer and that staff were to provide treatments as ordered. In an interview on May 31, 2023, at 11:20 a.m., Resident 116 stated that staff do not always provide wound care as ordered. Review of the treatment administration records for February through May 2023, revealed that treatments were not provided as ordered on February 4, 5, 10, and 14, March 2 and 16, April 3 and 20, and May 2,…

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 interview, it was determined that the facility failed to provide services to increase range of motion and/or prevent further decrease in range of motion for one of nine sampled residents with impairment. (Resident 3) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included diabetes mellitus and difficulty walking. The Minimum Data Set assessment dated [DATE], indicated that the resident was oriented and needed some staff assistance for activities of daily living, such as transferring and walking. A physical therapy Discharge summary dated [DATE], noted that the resident was evaluated for transferring positions, walking, and functional mobility. The discharge recommendations were for Resident 3 to have a home exercise program and to be referred for a restorative nursing program. On June 1, 2023, at 9:15 a.m. Resident 3 stated that staff did not assist her with restorative exercises. There was a lack of documentation 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 clinical record review, policy review, and staff interview it was determined that the facility failed to assess bladder incontinence for two of 25 sampled residents (Residents 116, 119) Findings include: Review of the facility policy entitled, Continence Management, last reviewed February 14, 2023, revealed that facility staff was to complete a urinary incontinence assessment upon admission or re-admission and with a change in condition or change in continence status. Clinical record review revealed that Resident 116 was admitted to the facility on [DATE], with diagnoses that included urinary tract infection and anemia. According to the Minimum Data Set (MDS) assessment, dated April 6, 2023, the resident was easily understood, and needed extensive assistance from staff for toileting. The assessment further indicated that the resident was frequently incontinent of urine and was not on a toileting program. There was no documentation in the clinical record to support that the resident's urinary…

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

Based on policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide tracheostomy care consistent with professional standards of practice for one of one sampled resident reviewed for tracheostomy. (Resident 45) Findings include: The facility policy entitled, Tracheostomy Care, last reviewed on February 14, 2023, revealed that tracheostomy care was to be done at least twice a day and as needed per physician's orders. The policy included a statement to cleanse under the trach holder and to replace the trach holder if soiled. Clinical record review revealed that Resident 45 had diagnoses that include acute respiratory failure with hypoxia, tracheostomy (an opening surgically made through the neck into the windpipe, which a tube/cannula allows the passage of air and supplemental oxygen), and laryngeal (voice box) cancer. Observation of Resident 45 on May 30, 2023, at 11:10 a.m. and May 31, 2023, at 10:40 a.m., revealed that Resident 45's tracheostomy collar was visibly soiled and encrusted with a dry green…

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, policy review, and staff interview, it was determined that the facility failed to adequately monitor residents on psychoactive medications for three of 25 sampled residents. (Residents 47, 50, 90) Findings include: Review of the facility policy entitled, Assessment Grid, dated February 14, 2023, revealed that staff was to assess and monitor a resident for abnormal involuntary movements and adverse side effects upon a new order for antipsychotic medication and every six months when on an antipsychotic medication. Clinical record review revealed that Resident 47 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder, major depressive disorder, and anxiety. Since admission, the physician ordered that the resident receive an antipsychotic medication (olanzapine). The care plan revealed that the resident was to be monitored for adverse side effects related to the use of this medication. There was no documentation in the clinical record to support 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.