Wecare At Sycamore Rehabilitation And Nursing Cent

Based on a review of select facility policies and procedures, clinical record review, review of employee personnel records, and staff interview, it was determined that the facility failed to develop written procedures for screening potential employees that included all necessary components, maintain documentation of potential employee employment history screening for three of five newly hired employees (Employees 5, 6, and 7), and failed to thoroughly investigate an injury of unknown origin for one of 24 residents reviewed (Resident 15). Findings include: Interview with the Nursing Home Administrator on March 13, 2026, at 11:14 AM confirmed that the facility's human resources and abuse prohibition program and policies do not include actions taken to screen prospective employees that include obtaining information from previous and/or current employers (e.g., dates of employment position or title, disciplinary actions, etc.), whether favorable or unfavorable. Review of Employee 5's (licensed practical nurse) personnel record revealed that the facility hired her on November 4, 2025.…

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, review of facility documentation, and staff and resident interview, it was determined that the facility failed to provide the highest practical care regarding physician ordered medications and/or devices for four of 24 residents reviewed (Residents 4, 11, and 12); and implement resident-directed care and treatment consistent with the resident's care plan for one of 24 residents reviewed (Resident 101). Findings include: A review of the current physician orders for Resident 11 revealed an order dated December 7, 2025, at 8:00 AM for Vitamin Deficiency System - B12 injection Kit; inject 1000 micrograms (mcg) intramuscularly one time a day every 30 days. A review of the Medication Administration Record (MAR) for Resident 11 for December 2025 to March 2026 revealed that the vitamin injection was not administered per the physician order for the following dates: February 5, 2026: no documentation on the MAR; blank.January 6, 2026: no documentation on the MAR; blank. There was no documentation for Resident 11 to indicate a rationale for why the medication…

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 select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and implement interventions to prevent falls for three of eight residents reviewed for fall concerns (Residents 14, 39, and 101). Findings include: The facility policy entitled, Falls - Clinical Protocol, reviewed without changes on February 10, 2026, revealed that the facility identified that many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. The staff and practitioner will review each resident's risk factors for falling and document in the medical record the examples of risk factors. Staff will document where and when they happen and any observations of the events. The staff and practitioner will begin to try to identify possible causes within 24 hours. Based on the assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically…

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 select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess all potential risks for entrapment for four of 13 residents reviewed for accident hazards (Residents 5, 8, 9, and 16) and failed to conduct ongoing assessments to assure appropriate maintenance with bedrail usage for two of 13 residents reviewed (Residents 8 and 16). Findings include: The facility policy titled, Enabler Bar Utilization for Bed Mobility, last reviewed on February 10, 2026, revealed (in part) that a nursing designee shall refer to maintenance for installation. Maintenance designee shall perform a complete bed system audit at time of installation/removal. Facility to ensure that no mattress, bolster/wedge, or enabler bar has gaps that are larger than recommended. All maintenance staff will be trained on how to properly measure the open spaces between the bed system components and assess the seven potential zones for entrapment as detailed by the Food and Drug Administration (FDA).…

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 documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with enteral tube feeding, who utilize a lift, catheter care, medication administration, donning and doffing PPE (personal protective equipment), and dressing changes for four of four employees reviewed for competencies (Employees 13,14, 10, and 16).Findings include: A review of the facility documentation revealed that the facility had a total of 119 residents receiving medications, 28 residents that utilize lifts, nine residents with indwelling urinary catheters (insertion of a tube into the bladder to remove urine), 17 residents with dressing changes, two residents with enteral tube feedings (device that allows liquid food to enter your stomach or intestine through a tube), and eight residents on transmission based precautions. A request for nursing staff competencies for enteral tube feeding, lifts, catheter care, medication administration,…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (Resident 51).Findings include: The facility's medication error rate was 9.68 percent based on 31 medication opportunities with three medication errors. Before commencing with the medication administration pass, Employee 10 (registered nurse) confirmed on March 11, 2026, at 8:32 AM knowledge of the instructions to alert the surveyor of any medications scheduled but not administered for this medication administration pass to avoid an error of omission. During the observation of a medication administration pass for Resident 51, Employee 10 reported that she would not administer Resident 51's scheduled Vitamin D (vitamin supplement) or Refresh tears (artificial lubrication drops for eyes) on March 11, 2026, at 8:32 AM due to their unavailability in the medication cart. Employee 10 prepared a dose of Clear Lax (polyethylene glycol, Miralax, stool softener) 17 grams (gm) for Resident 51. The labeling on the medication…

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 select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection on three of five nursing units (Maple Court, Sycamore, and Little League; Residents 4, 11, 15, 37, 51).Findings include: Review of the facility policy entitled, Coronavirus Disease (COVID-19)- Testing Residents, last reviewed without changes on February 10, 2026, revealed that residents are to be tested for the SARS-CoV-2 virus (Severe Acute Respiratory Syndrome Coronavirus 2) to detect the presence of current infections and to help prevent the transmission of COVID-19 in the facility. Asymptomatic residents who have had close contact with someone that has the SARS-CoV-2 infection, will have a series of three viral tests for SARS-CoV-2 infection. Testing is conducted immediately (but not earlier than 24 hours after exposure) and, if negative, again 48 hours after the first negative test, and if negative again, 48 hours after the second negative test. An outbreak investigation is…

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

Based on staff interview it was determined that the facility failed to maintain documentation of staff COVID-19 vaccination status, and provide evidence that staff were offered the COVID-19 vaccine or information on obtaining the COVID-19 vaccine for three of three staff reviewed. (Employees 11, 18, and 19) Findings include: Interview with the Director of Nursing on March 13, 2026, at 2:53 PM revealed that she is unable to provide evidence that the facility maintained staff documentation of screening, education, offering of COVID-19 vaccinations, and their current COVID-19 vaccination status. She indicated that she had a call out to the previous infection preventionist to see where the documentation may be but has not received a response. There was no evidence of the above for information for Employee 11 (housekeeper), Employee 18 (licensed practical nurse), or Employee 19 (nurse aide). The facility failed to offer staff the COVID-19 vaccine or provide them with information on where to obtain the vaccine, and failed to maintain staff documentation of screening, education, offering…

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

Based on observation, and staff and resident interview, it was determined that the facility failed to accommodate resident needs, creating a homelike environment for one of 24 residents reviewed (Resident 7). Findings include: Observation and interview with Resident 7 on March 10, 2026, at 12:29 PM revealed upon entering the room Resident 7's eyes were closed and the light above his bed was on. Resident 7 stated that the light is on all the time. He stated he sleeps with the light on because he cannot reach it to turn it off. He stated staff are busy, so he stopped asking them. Further observation revealed the switch is on the wall behind Resident 7's bed, out of his reach. Resident 7 stated that he sleeps with the light on every day. Further observations on March 11, 2026, at 8:09 AM and March 12, 2026, at 8:13 AM revealed Resident 7 was in his bed with his light on. The facility failed to accommodate Resident 7's needs, creating a homelike environment, relating to his light. The surveyor reviewed the above concern regarding Resident 7's light during an interview with the Nursing…

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 select facility policies and procedures, clinical record review, review of the facility's grievance log, and staff interview, it was determined that the facility failed to address a grievance promptly and implement effective actions to resolve the reported grievance for one of 24 residents reviewed (Resident 90).Findings include: The facility policy entitled Skilled Nursing Facility Grievance Policy, last reviewed without changes on February 10, 2026, revealed every grievance will be addressed promptly and appropriately, in accordance with federal and state regulations. Residents or representatives may submit grievances verbally, in writing, or anonymously. The grievance official, or designee will acknowledge receipt of the grievance within three business days. The acknowledgement will include the date the grievance was received, the name and title of the grievance official, steps being taken to investigate, and an expected timeframe for resolution. All grievances will be investigated promptly, objectively, and thoroughly. Documentation of interviews, 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.

Based on clinical record review and family and staff interview it was determined that the facility failed to provide written notice of transfer that included all the necessary contents to residents' responsible parties at the time of transfer for four of eight residents reviewed for hospitalizations (Residents 4, 5, 9, and 7); failed to provide timely written notice of the facility bed-hold policy to residents' responsible parties at the time of transfer for three of eight residents reviewed for hospitalizations (Resident 5, 9, and 7); and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for three of eight residents reviewed for hospitalizations (Residents 5, 9, and 7). Findings include: Interview with Resident 9's daughter on March 10, 2026, at 9:58 AM indicated that she did not receive any written notices related to the facility's bed-hold policy or the reasons for Resident 9's transfer to the hospital when she went to the hospital recently. Resident 9's daughter confirmed that someone from the facility telephoned her to report her…

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 assessments accurately reflected a resident's status for one of 24 residents reviewed (Resident 43). Findings include: Clinical record review for Resident 43 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated February 1, 2026, that facility staff assessed Resident 43 as receiving an antibiotic medication during the last seven days in the assessment period. Further clinical record review revealed no evidence that Resident 43 received an antibiotic medication during the assessment period for the MDS noted above. Interview with Employee 9 (registered nurse assessment coordinator) on March 12, 2026, at 9:54 AM confirmed that Resident 43's February 1, 2026, MDS was coded in error regarding receiving an antibiotic medication. Review of a significant change MDS dated [DATE], revealed staff assessed Resident 43 as having no…

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, observation, and resident and staff interview, it was determined that the facility failed to revise a resident's comprehensive care plan for one of 24 residents reviewed (Resident 3) and failed to invite and ensure resident and/or responsible party participation in care plan meetings for 1 of 24 residents reviewed (Resident 28).Findings include: Clinical record review for Resident 3 revealed a current care plan that was initiated on November 20, 2025, and indicated she had an indwelling urinary catheter related to a neurogenic (a dysfunction of the bladder due to nerve damage) bladder. Further clinical record review revealed her indwelling urinary catheter was discontinued on November 22, 2025. Clinical record review for Resident 3 revealed a current care plan that was initiated on November 28, 2025, and indicated that she was utilizing a psychotropic medication. Further clinical record review revealed that her psychotropic medication was discontinued on January 29, 2026. Further clinical record review for Resident 3 revealed that the facility staff…

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

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide a dependent resident with activities of daily living assistance for one of four residents reviewed (Resident 7).Findings include: Observation of Resident 7 on March 10, 2026, at 12:32 PM revealed he was in bed and his hair appeared long and disheveled. Interview with Resident 7 at this time revealed he has been waiting to get his hair cut. Resident 7 stated that he prefers his hair to be short, stating that he was in the military. Clinical record review revealed the facility admitted Resident 7 on March 2, 2023. Review of Resident 7's care plan-initiated March 3, 2023, revealed Resident 7 wished to use the facility's beautician. Further review of Resident 7's plan of care-initiated July 22, 2025, revealed Resident 7 has an activity of daily living self-care performance deficit, noting he requires substantial to maximum assistance for personal hygiene. The findings for Resident 7 were reviewed with the Director of Nursing on March 12, 2026, at 12:07…

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 maintain a resident's range of motion for two of seven residents reviewed for ROM concerns (Resident 3 and 45). Findings include: Interview of Resident 3 on March 11, 2026, at 10:46 AM revealed that she has an impairment to her left hand, limiting her range of motion in two of her fingers. She indicated that since she came off of therapy, she does not get any exercise. On March 12, 2026, at 12:10 PM the facility provided surveyor with a copy of a home exercise program that was provided to Resident 3 to do in her room. The program was provided to her on February 5, 2026, and addressed exercise for her lower extremities. Concurrent interview with the director of nursing revealed that the exercise program was for Resident 3 to do on her own and that there is no documentation that she does the program and there is no one assigned to make sure she does the program. Interview of Resident…

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

Based on clinical record review, review and staff interview, it was determined that the facility failed to provide appropriate treatment and services regarding incontinence management for one of one resident reviewed (Resident 3). Findings include: Clinical record review for Resident 3 revealed that the facility admitted her on November 20, 2025, with a urinary catheter (a flexible tube inserted into the bladder to drain urine) in place due to a diagnosis of neuromuscular dysfunction of the bladder (a loss of bladder control caused by nerve damage from illnesses or injuries). Further clinical record review for Resident 3 revealed that her urinary catheter was discontinued on November 21, 2025. Her clinical record also indicated that she had a three-day bowel and bladder pattern tool (a worksheet completed by staff documenting continent and incontinent episodes in order to determine a pattern) completed November 21-23, 2025. Review of the 3-day bowel and bladder pattern tool revealed that on November 21, 2025, staff did not document after 3:00 PM, on November 22, 2025, staff did not…

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 family and staff interview, it was determined that the facility failed to implement interventions to maintain nutritional status for one of seven residents reviewed for nutritional concerns (Resident 9).Findings include: Interview with Resident 9's daughter on March 10, 2026, at 10:03 AM revealed that she believed that her mother had lost weight. Clinical record review for Resident 9 revealed the following weight assessments: December 3, 2025, 202.4 pounds December 10, 2025, 200 poundsDecember 17, 2025, 199.7 poundsDecember 23, 2025, 186 pounds (a 16.4-pound, 8.1 percent, severe weight loss in the three weeks since her admission)December 29, 2025, 190.4 poundsDecember 30, 2025, 190.4 poundsJanuary 3, 2026, 184.6 poundsJanuary 15, 2026, 184.6 poundsJanuary 31, 2026, 185.2 poundsFebruary 1, 2026, 185.2 poundsFebruary 2, 2026, 185.2 poundsFebruary 10, 2026, 176.8 pounds (a 7.8-pound, 4.2 percent loss in one month)February 13, 2026, 158.4 pounds (an 18.4-pound, 10.4…

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 respiratory care consistent with professional standards of practice for one of one resident reviewed with oxygen concerns (Resident 7) and maintain respiratory related equipment supplies in a safe and sanitary manner in one of one dining room observed (main dining room).Findings include: Observation of the main dining room on [DATE], at 8:25 AM during the initial tour of the kitchen revealed a suction unit on a red colored wheeled cart. Two bottles of sterile water kept with the suction unit were expired on [DATE]. The cart also had extensive debris noted on the shelving. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on [DATE], at 2:05 PM. Clinical record review revealed the facility admitted Resident 7 on [DATE], with a diagnosis of chronic obstructive pulmonary disease added [DATE]. Observation of Resident 7 on [DATE], at 11:02…

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, observation, and resident and staff interview, it was determined that the facility failed to implement appropriate care and services related to dialysis care for one of one resident reviewed for dialysis concerns (Resident 28).Findings include: Clinical record review for Resident 28 revealed the following active physician orders: Dialysis (medical procedure to filter blood outside the body to remove waste and excess fluids when the kidneys can no longer function adequately) three times a week Obtain a full set of vital signs (typically temperature, pulse, respiration, and blood pressure assessments) before and after dialysis every day and evening shift every Tuesday, Thursday, and Saturday; no BP (blood pressure) in right arm Do not take B/P (blood pressure) on right arm Monitor catheter site for pain, redness, swelling, bleeding. If noted bleeding, apply pressure dressing and notify provider every day and evening shift for dialysis Renal (kidney) diet, regular texture, thin consistency (for fluids), 1200 ml (milliliter) fluid restriction Fluid…

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 identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for two of two residents reviewed for mood and behaviors (Residents 12 and 43). Findings include: Clinical record review for Resident 12 revealed a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) dated March 10, 2023. Clinical record review for Resident 12 revealed a quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated January 23, 2026, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 10, which indicated cognitive impairment. The MDS further revealed that the resident was assessed as yes to having a PTSD diagnosis. A Psychosocial Evaluation for Resident 12 dated July 30, 2025, at 2:16 PM 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 observation and staff interview, it was determined that the facility failed to properly store resident medications on two of six nursing units reviewed (Little League Nursing Unit and Sycamore Nursing Unit). Findings include: Observation during the medication pass on the Little League Nursing Unit and Sycamore Nursing Unit on March 12, 2026, at 9:06 AM revealed a medication cart being utilized by Employee 21, licensed practical nurse. Observation of the medication cart revealed the following: There were several unsecured and unidentified medication tablets found in the bottom of the drawers that included: a pink colored round pill, a white colored round pill, a blue colored oblong tablet, a half a pink tablet, a half of a round white colored pill, a large white colored round pill, a smaller white colored round pill, a scored pink pill, and numerous other loose medications in the bottom of the drawers that held the pre-packaged pill packets. There was also a significant accumulation of debris in the bottom of the drawers that held the loose medications. A concurrent…

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

Based on observation and staff interview, it was determined that the facility failed to assure essential kitchen equipment is maintained in a safe, operating condition in the facility's main kitchen. Findings include: Initial tour of the facility's main kitchen with Employee 17, dietary manager, on March 10, 2026, at 8:25 AM revealed the following: Staff were observed serving breakfast from a steam table located in the facility's main kitchen. A large cooking pan that was more than halfway filled with water was observed on the floor under the steam table. A concurrent interview with Employee 17 revealed that there was a leak from the steam table that has been present since at least December 2025. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on March 12, 2026, at 2:05 PM. A walk-in cooler for the main kitchen located in the basement of the facility had a light receptacle in the ceiling of the cooler that had no light bulbs in it. There was water observed dripping off the receptacle and pooling on the ground. It was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select policies and procedures, observation, and resident and staff interview, it was determined that the facility failed to serve food that is palatable on four of six nursing units (Nursing Units [NAME], Little League, Sycamore, and Grampian; Residents 1, 2, 3, 4, 5, 6, and 7). Findings include: The current facility policy entitled Food Temperature Recording, revealed all hot foods will be held and served at or above 135 degrees Fahrenheit, and all cold foods will be held and served at or below 41 degrees Fahrenheit. Interview with Residents 1 and 2 on December 13, 2025, at 6:37 AM revealed their food is frequently cold, they said the time they receive their meal trays is different every day. Interview with Resident 4 on December 13, 2025, at 7:02 AM revealed that her food is occasionally cold. She stated she just doesn't eat it if it is cold. Interview with Resident 3 on December 13, 2025, at 8:53 AM revealed that her meal tray is frequently late and is cold when she gets it. Interview with…

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

Based on observations and interview with residents and staff, it was determined the facility failed to reasonably accommodate residents who may wish to eat outside of scheduled meal service times on six of six nursing units (Residents 1, 2, and 4). Findings include: Interview with Residents 1 and 2 on December 13, 2025, at 6:37 AM revealed that they do not receive snacks. They stated staff tell them there are no snacks in the nourishment rooms. Interview with Resident 4 on December 13, 2025, at 7:02 AM revealed that she does not receive snacks. Interview with Employee 1 (food service director) and observation of the nutrition rooms on each nursing unit on December 13, 2025, from 8:30 to 8:45 AM confirmed there were no snacks available for residents who wish to eat outside of scheduled meal service times. Employee 1 confirmed these findings at this time. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on December 13, 2025, at 10:00 AM. 28 Pa. Code 201.14(a) Responsibility of licensee

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding neurological assessments for one of five residents reviewed. Findings include: The current facility policy entitled Neurological Assessment, revealed neurological assessments are indicated following an unwitnessed fall. When assessing neurological status, always include frequent vital signs, particular attention should be paid to widening pulse pressure (difference between systolic and diastolic pressures) as this may be indicative of increasing intracranial pressure. Any change in vital signs or neurological status in a previously stable resident should be reported to the physician immediately. Closed clinical record review for Resident CR1 revealed nursing documentation dated [DATE], at 10:32 PM noting Resident CR1 was found in her bathroom, face down on the floor. The registered nurse assessed Resident CR1 before…

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

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 provide required notification to a resident whose payment coverage changed for three of three residents reviewed (Residents 72, 101, and CR119). Findings include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then 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 clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide bathing assistance for residents dependent on staff assistance for 5 of 6 residents sampled for activities of daily living (Residents 22, 92, 7, 43, and 70). Findings include: Observation of Resident 22 on February 18, 2025, at 10:32 AM and February 19, 2025, at 10:40 AM revealed she was in bed and her hair appeared disheveled. Attempts to interview Resident 22 at these times related to her showers were unsuccessful. Resident 22 stated she was unable to remember when she last had a bath or shower. Clinical record review revealed the facility admitted Resident 22 on September 25, 2023. A review of Resident 22's most recent MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated January 23, 2025, indicated nursing staff assessed Resident 22 as dependent on staff for bathing. A review of Resident 22's task documentation (ADL, activities of…

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

Based on clinical record review, observation and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician orders, medications, and treatments for six of 22 residents reviewed (Residents 22, 33, 42, 70, 109, 112, and 114). Findings include: Clinical record review for Resident 42 revealed physician orders for staff to administer the following: Atorvastatin Calcium 20 milligrams (mg) at bedtime for hyperlipidemia (high fat in bloodstream) Senna 2 tablets at bedtime for constipation Tums 500 mg 2 tablets at bedtime for GERD (reflux) Acetaminophen Extended Release 650 mg BID (twice daily) for mild pain 1-3 Famotidine 20 mg every 12 hours for stomach ulcers Tramadol 50 mg one-half tablet BID for pain Review of Resident 42's January 2025, MAR (medication administration record, a form to document medication administration) revealed that there was no documentation that staff administered their medications on January 28, 2025, during the evening shift. Clinical record review for Resident 70 revealed physician orders…

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 provide the highest practicable care regarding physician ordered pain medications for two of three residents reviewed (Residents 6 and 43) Findings include: Clinical record review for Resident 6 revealed physician orders for the following pain medications: Ordered on July 18, 2024, Acetaminophen (Tylenol, for mild pain) 325 milligrams (mg) 2 tablets by mouth (PO) every 6 hours as needed (PRN) for a pain scale of 1-3. Ordered on December 20, 2024, and discontinued on February 6, 2025, Oxycodone (for moderate to severe pain) 5 mg two tablets PO every 6 hours PRN for a pain scale of 8-10. Ordered on January 16, 2025, Oxycodone 5 mg one tablet PO every 6 hours PRN for a pain scale of 4-7. Ordered on January 16, 2025, and discontinued on February 6, 2025, Oxycodone 5 mg two tablets PO every 6 hours PRN for a pain scale of 8-10. Ordered on February 6, 2025, Oxycodone 10 mg one tablet PO every 6 hours PRN for a pain scale of 8-10. There was no documentation that the facility identified 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interview, it was determined that the facility failed to review the risk and benefits of side rail utilization with the resident or resident representative and receive consent for the use of side rails for four of five residents reviewed for accident hazards (Residents 33, 42, 70, and 109), and properly assess all zones that pose a risk for entrapment from bed rails on two of five residents reviewed (Residents 33 and 109). Findings include: Observation of Resident 42's room on February 18, 2025, at 12:14 PM and February 20, 2025, at 8:32 AM revealed that there were bilateral circular halo-type enabler bars on the bed. Clinical record review for Resident 42 revealed that the facility completed an enabler bar evaluation dated September 20, 2023, and again on December 17, 2024, which indicated that they passed for potential entrapment. There was no documentation that indicated the facility received consent from Resident 42 or their responsible party to utilize…

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 documentation and staff interview, it was determined that the facility failed to ensure that nurse aides received an annual performance review and at least 12 hours of in-service education annually for three of three nurse aides reviewed (Employees 10, 11, and 12). Findings Include: Review of available personnel documentation for Employee 10 (nurse aide) revealed that the facility hired her on September 12, 2023. Interview with the Nursing Home Administrator on February 20, 2025, at 2:38 PM revealed that the facility could not provide evidence of an annual performance review (due September 2024) for Employee 10. Review of available personnel documentation for Employee 11 (nurse aide) revealed that the facility hired him on November 15, 2022. A performance evaluation signed by Employee 11 on April 8, 2024, indicated that the evaluation included a period of evaluation from November 15, 2022, to November 15, 2023. Interview with the Nursing Home Administrator on February 21, 2025, at 10:02 AM confirmed that the facility had no evidence to indicate a…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure laboratory reports were in residents clinical records for 3 of 22 residents reviewed (Residents 22, 92, and 46). Findings include: Review of Resident 22's clinical record on February 20, 2025, revealed a physician's progress note dated January 13, 2025, at 3:30 PM noting Resident 22's physician requested staff obtain a CBC (complete blood count, a group of blood tests that measure the number and size of the different cells in your blood), BMP (basic metabolic panel, a group of blood tests that assess various aspects of metabolism, electrolyte balance, and kidney function), BNP (B-type natriuretic peptide, test to rule out heart failure), and Troponin (test to diagnose a heart attack, or monitor heart damage), and labs stat (a quick turnaround time, generally an hour or less). There was no evidence in Resident 22's clinical record of the above-mentioned laboratory tests. Review of Resident 92's clinical record on February 20, 2025, revealed a physician's progress note dated…

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

Based on observation and staff interview, it was determined that the facility failed to store food in accordance with professional standards for food service safety in the facility's main kitchen. Findings include: Initial tour of the facility's main kitchen on February 18, 2025, at 9:03 AM with Employee 5 (director of dining services) revealed the following: The refrigerator had a tray of ground beef thawing above a shelf with eggs. The refrigerator had three opened containers of beef base, with a date of September 7, 2024. There was a fourth container of beef base with no date. The refrigerator contained a large container of lemon juice with a use by date of January 18, 2025. The refrigerator contained a large container of salsa with a use by date of January 25, 2025. The refrigerator contained a large container of mustard with a use by date of April 8, 2024. The refrigerator contained a large container of BBQ sauce with a use by date of February 7, 2025. Interview with Employee 5 on February 18, 2025, at 9:31 AM revealed that dietary staff are expected to mark food items with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection on two of five nursing units (Grampian: Residents 109, 112, 113, and 223; and Sycamore: Resident 22). Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) memo entitled, Enhanced Barrier Precautions in Nursing Homes, dated March 20, 2024, revealed that nursing care facilities are to use enhanced barrier precautions (EBP, gown and glove use) for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Observation of Resident 223 on February 19, 2025, at 10:41 AM revealed tubing from an indwelling urinary catheter (flexible tubing…

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 honor advance directive choices for one of 22 residents reviewed (Resident 53). Findings include: Clinical record review for Resident 53 revealed that on [DATE], their physician ordered staff to Do Not Resuscitate (DNR), which continued throughout the resident's facility stay until February 20, 2025, after identified by the surveyor. There was documentation on February 7, 2025, at 1:35 PM that indicated the facility contacted Resident 53's responsible party to complete a POLST (Pennsylvania Orders for Life-Sustaining Treatment, a form directing medical staff to complete life-sustaining treatment or allow a natural death) form. On February 11, 2025, Resident 53's responsible party completed the POLST and indicated that staff should complete CPR (cardiopulmonary resuscitation) should the need arise. On February 11, 2025, at 8:10 AM staff acknowledged that Resident 53's responsible party completed a POLST form the day…

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 select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to report an allegation of misappropriation of resident property for one of three closed records reviewed (Resident 118, Employee 2). Findings include: The facility policy entitled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, last reviewed without changes January 23, 2025, revealed all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator, and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. the state…

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 and resident interview it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 22 residents reviewed (Resident 113). Findings include: Clinical record review for Resident 113 revealed an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], that indicated he received five insulin (injectable hormone medication used to lower blood sugar) injections during the previous seven days (or since his admission to the facility). Interview with Resident 113 on February 19, 2025, at 10:21 AM revealed that he had never received an insulin injection, and that he does not have a diabetes diagnosis (medical condition that results in elevated blood sugar). Interview with the Nursing Home Administrator on February 21, 2025, at 9:33 AM confirmed that the MDS assessment that indicated Resident 113 received insulin injections was completed in…

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

Based on clinical record review, facility documentation, and staff interview, it was determined that the facility failed to provide an ongoing program of activities designed to meet the individual needs and interests for one of one resident reviewed for activities (Resident 7). Findings include: Review of Resident 7's current care plan revealed Resident 7 was dependent on staff for meeting emotional, intellectual, physical, and social needs. Interventions included to invite Resident 7 to scheduled activities of possible interest including mass, musical programs, holiday or celebratory events, live entertainment, pet visits, and craft activities. Resident 7's care plan noted she needs assistance, or escort to activity functions, may need some reassurance and assistance with communication during activities, and she enjoys playing with her busy blanket. Observation of Resident 7 on February 18, 2025, at 9:53 AM, 1:38 PM, and 3:27 PM revealed Resident 7 was in a wheelchair sitting at the nurses' station. Resident 7 did not have her busy blanket. Observation of Resident 7 on February 19,…

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

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 provide services to maintain a resident's range of motion for one of four residents reviewed for ROM concerns (Resident 7). Findings include: Clinical record review revealed the facility admitted Resident 7 on December 2, 2015. Review of Resident 7's most recent quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated November 22, 2024, noted staff assessed Resident 7 as having no upper or lower extremity impairments. Further review of Resident 7's clinical record revealed her next MDS assessment dated [DATE], nursing staff assessed Resident 7 as having a limited range of motion (ROM, movement of the body to maintain a resident's ability) bilaterally to her upper and lower extremities. Review of Resident 7's clinical record revealed she was discharged from physical therapy on December 26, 2024, and occupational therapy on November 15, 2024. The facility was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to assess and implement individualized interventions to promote bowel and bladder continence for one of one resident reviewed for incontinence (Resident 55). Findings include: Clinical record review revealed the facility admitted Resident 55 on January 20, 2025. Review of Resident 55's admission MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) assessment dated [DATE], revealed that staff assessed Resident 55 as frequently incontinent of his bowel and bladder, with no attempts at a toileting program. Staff also assessed Resident 55 as dependent on staff for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). Review of Resident 55's care plan initiated on January 21, 2025, revealed that Resident 55 has an activities of daily living self-care performance deficit related to his impaired balance 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 observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for three of three residents reviewed (Residents 22, 6, and 70). Findings include: Observation of Resident 22 on February 18, 2025, at 10:32 AM and 2:02 PM revealed Resident 22 was in bed with a nasal cannula (NC, tubing to deliver oxygen to the nose) on and running at 4 liters per minute (LPM). Observation of Resident 22 on February 19, 2025, at 8:17 AM and 12:57 PM revealed Resident 22 was in bed with oxygen on and running at 4 LPM. Observation of Resident 22 on February 20, 2025, at 12:20 PM revealed Resident 22 was in bed with oxygen on and running at 4 LPM. Review of Resident 22's clinical record revealed there was no physician's order for Resident 22 to receive oxygen. Review of Resident 22's care plan-initiated November 23, 2023, noted Resident 22 had a risk for ineffective breathing patterns related to the use of oxygen. The Nursing Home Administrator and Director of Nursing confirmed these finding during a meeting…

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, observation, and resident and staff interview, it was determined that the facility failed to implement care to prevent potential complications from a dialysis access site for one of one resident reviewed for dialysis concerns (Resident 112). Findings include: Interview with Resident 112 on February 18, 2025, at 1:17 PM revealed that he required dialysis treatments (treatment for kidney failure; a machine filters extra fluid and waste products from the blood) three times a week; and that the treatment was administered through an access site (central venous catheter (CVC), tubing inserted into a large central vein, most commonly the internal jugular or subclavian) in his right upper chest. Resident 112 stated that he was unaware of any equipment in his room that would be available in the event of a complication from his dialysis access site (e.g., pressure dressings or clamp). Observation of Resident 112 and his room during the interview revealed no indicators that Resident 112 had right arm use restrictions (e.g., a sign to warn a contracted…

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 documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to the care and assessment of residents with indwelling urinary catheters, cardiac pacemaker devices, and central venous catheters, for three of three employees reviewed for competencies (Employees 2, 8, and 9; Residents 112 and 114). Findings include: A review of the facility Resident Matrix (CMS-802, form used to identify pertinent care categories for residents who reside in the facility) documentation revealed that the facility had a total of 13 residents with indwelling catheters (insertion of a tube into the bladder to remove urine) within the 107 resident facility census (over 12 percent). The surveyor requested evidence of licensed nursing staff competencies related to indwelling urinary catheters for Employee 2 (registered nurse) and Employee 8 (licensed practical nurse) during an interview with the Nursing Home Administrator, Director of Nursing, and Employee…

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 family and staff interview, it was determined that the facility failed to provide behavior health care that was individualized to attain or maintain the highest practical physical, mental, or psychosocial well-being for one of two residents reviewed for mood and behavior concerns (Resident 221). Findings include: Interview with Resident 221's daughter on February 18, 2025, at 10:16 AM revealed that she characterized her mother as detached, and she believed an increase in her mother's antidepressant medication dose might lessen her symptoms of depression. Resident 221's daughter stated that she did not believe that her mother had a good appetite or was attending many activities at the facility. Clinical record review for Resident 221 revealed that the facility admitted her on February 12, 2025. Active physician orders for Resident 221 dated February 12, 2025, included the following psychoactive medications: Mirtazapine (an antidepressant) 15 mg (milligrams) at bedtime 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 clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of three residents reviewed (Resident 91). Findings include: Clinical record review for Resident 91 revealed the facility admitted her on December 9, 2022, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 91's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated November 2, 2024, indicated that the facility assessed Resident 91 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 91's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. The findings were reviewed with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to ensure the proper disposal and documentation of controlled medications for one of three discharged residents reviewed (Resident 118). Findings include: The facility policy entitled Controlled Substances, last reviewed without changes on [DATE], revealed the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Waste or disposal of controlled medications are done in the presence of the nurse and a witness who also signs the disposition sheet. Closed clinical record review for Resident 118 revealed the facility admitted her on [DATE]. Resident 118 remained in the facility until [DATE], when she was sent to the hospital and later expired. Review of Resident 118's closed record revealed a Controlled Drug Receipt/Record/Disposition Form dated [DATE], indicating 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, observation, and staff interview, it was determined that the facility failed to ensure that medication labeling was in accordance with currently accepted professional standards and active physician orders for one of eight residents reviewed for medication administration (Resident 221). Findings include: Observation of a medication administration pass on February 19, 2025, at 11:27 AM revealed Employee 4 prepared medications for Resident 221. Employee 4 poured one capsule of Dicyclomine (medication used to decrease muscle spasms in the stomach or bowel to treat symptoms of irritable bowel syndrome). The label on the medication packaging indicated the medication was packaged as 10 milligrams (mg) per each capsule. Clinical record review for Resident 221 revealed that active physician orders since February 12, 2025, instructed staff to administer one capsule of Dicyclomine HCl four times a day. The physician's order did not include the strength of the medication desired (e.g., 10 mg). Continued observation of a medication administration pass 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 clinical record review, observation, and staff interview, it was determined that the facility failed to assist a resident to obtain routine dental care for one of one resident reviewed for dental concerns (Resident 46). Findings include: Observation of Resident 46 on February 18, 2025, at 10:41 AM and February 19, 2025, at 11:30 AM revealed he was in bed. Attempted to interview Resident 46 several times and he refused to answer questions, stating he was too tired and would not open his eyes. Observation of Resident 46's teeth at these times revealed what appeared to be a buildup of plaque on his teeth. Clinical record review revealed the facility admitted Resident 46 on February 22, 2018, with payment sources that included the state Medicaid benefit. Review of Resident 46's clinical record revealed he saw a dentist on April 12, 2023. A review of the progress note revealed Resident 46 had a heavy buildup of plaque, and he would be due for his next visit for prophylactic dental cleaning in six months. Further review of Resident 46's clinical record revealed he did not receive…

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 Quality Assessment and Assurance (QAA) meeting attendance and staff interview it was determined that the facility failed to ensure the committee consisted of the minimum members (medical director and Director of Nursing) at least quarterly. Findings include: Review of QAA meeting attendance records dated April 2024, to the final date of the onsite survey, February 21, 2025, revealed that the facility's most recent QAA committee meeting occurred on December 23, 2024. Attendance records indicated that the facility medical director did not attend a QAA meeting in the almost seven months since July 25, 2024, and the Director of Nursing did not attend a QAA meeting in the almost four months since October 24, 2024. Interview with the Nursing Home Administrator on February 21, 2025, at 9:26 AM confirmed that the facility failed to ensure at least quarterly QAA meeting attendance by the Director of Nursing and the facility's medical director (or designee). 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3)(e)(3) Management

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 a residents medical record included documentation that the residents representative was provided education regarding the risks and benefits of the influenza immunization for one of five residents reviewed for immunization concerns (Resident 92). Findings include: Clinical record review for Resident 92 revealed a quarterly MDS (Minimum Data Assessment, an assessment tool completed at specific intervals to determine care needs) assessment dated [DATE], indicated the resident had a BIMS (Brief Interval for Mental Status) score of eight, indicating he had moderate cognitive impairment. Review of Resident 92's immunization documentation revealed that Resident 92's family refused for him to have an influenza (flu) vaccination on August 14, 2024. The documentation also indicated that the facility did not provide the family with education related to the risk and benefits of the influenza vaccination. 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 staffing documents and staff interview, it was determined that the facility failed to designate a registered nurse (RN) as the Director of Nursing on a full time basis from November 11, 2024, to December 7, 2024. Findings include: Interview with the Nursing Home Administrator (NHA) on December 9, 2024, at 1:30 PM revealed that Employee 1 (Registered Nurse and Interim Director of Nursing) does not work at least 35 hours a week as a DON because she is needed to cover as the Registered Nurse on the nursing care units. Review of the interim DON's timecard for the weeks of November 10-23, 2024, and November 24-December 7, 2024, revealed that Employee 1 only worked two days as the interim Director of Nursing and was utilized as the Registered Nurse on the nursing care units on the following dates: November 11, 2024 November 12, 2024 November 13, 2024 November 14, 2024 November 18, 2024 November 19, 2024 November 20, 2024 November 21, 2024 November 22, 2024 November 25, 2024 November 26, 2024 November 27, 2024 November 29, 2024 December 2, 2024 December 3,…

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 notify the responsible party of a resident's change in condition requiring interventions for one of six residents reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed a progress note dated August 31, 2024, at 10:06 AM indicating that a nurse aide notified the nurse that Resident CR1 had some areas on his toes that she noted when she showered him. The nurse's observation revealed wounds on the right second toe, left great toe, and left second toe that were described as thick, brown/green scabbed-like areas with no drainage. The nurse added Resident CR1 to the wound nurse list and left a communication note for the physician. She then cleansed the areas, applied betadine, and left them open to air. The treatment was to continue until the resident was seen by the wound nurse. There was no documentation in the clinical record indicating that the responsible party was notified of the wounds on Resident CR1's toes, the treatment that was ordered,…

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

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to provide the necessary treatment and services consistent with professional standards of practice for the prevention of a pressure ulcer for one of five residents reviewed for pressure ulcers (Resident 3). Findings include: Clinical record review for Resident 3 revealed that the facility admitted her on August 28, 2024, with a diagnosis of a fractured right lower leg. Review of Resident 3's admission MDS (Minimum Data Set, an assessment completed by the facility at intervals to determine care needs), dated September 1, 2024, revealed that she required extensive assistance with bed mobility, transfers, and toilet use. The MDS also indicated that she was at risk for pressure ulcer development but currently did not have any pressure ulcers. A nursing progress note dated September 23, 2024, at 11:04 AM revealed that Resident 3 had some openings on her bilateral buttocks, and she will not lay in bed to get off the areas. The note indicated that she denied pain and that she had…

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

Based on staff interviews and review of facility documentation, it was determined that the facility failed to ensure that nurse aides received an annual performance review for three of three nurse aides reviewed (Employees 3, 4, and 5). Findings Include: Review of the facility's list of active nurse aide staff revealed Employee 3 had a hire date of November 15, 2022. Employee 3 should have had an annual performance review by November 15, 2023. Employee 4 had a hire date of November 15, 2022. Employee 4 should have had an annual performance review by November 15, 2023. Employee 5 had a hire date of November 15, 2022. Employee 5 should have had an annual performance review by November 15, 2023. Requests to review Employees 3, 4, and 5's performance reviews revealed no documented evidence that the facility completed the reviews at least once every 12 months. Interview with the Nursing Home Administrator on March 14, 2023, at 10:50 AM confirmed that performance evaluations were not completed. 28 Pa. Code 201.19(2) Personnel policies and procedures

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility's bed hold policy at the time of transfer for six of 10 residents reviewed for hospitalizations (Residents 3, 10, 44, 45, 62, and 69). Findings include: Clinical record review for Resident 10 revealed that she was transferred to the hospital on December 13, 2023, for respiratory distress. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer out of the facility. Clinical record review for Resident 45 revealed that she was transferred to the hospital on December 27, 2023, related to pneumonia. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer out of the facility. Clinical record review for Resident 62 revealed that he was transferred to the hospital on October 31,…

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, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician-ordered vital signs, medications, and interventions for two of 22 residents (Residents 8 and 52) and integrated hospice care and services for two of four residents reviewed (Residents 34 and 75). Findings include: Clinical record review for Resident 8 revealed a current physician order for staff to place an air mattress on her bed and monitor the air mattress every shift to ensure the pump setting was 220 (pounds) alternating pressure for skin protection. Observation of Resident 8's air mattress on March 12, 2023, at 9:54 AM, March 13, 2024, at 11:21 AM, and March 14, 2024, at 8:28 AM and 10:45 AM revealed that her air mattress pump setting was 380 pounds. Further clinical record review for Resident 8 revealed a physician order for staff to administer Detemir insulin 100 unit/milliliter 37 units subcutaneously (just under the skin) daily for diabetes. Staff were to hold the insulin if Resident 8's blood sugar was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview, it was determined that the facility failed to assess and implement treatment and services to prevent development and promote healing of pressure ulcers for four of six residents reviewed for pressure ulcer concerns (Residents 15, 22, 34 and 260). Findings include: Clinical record review for Resident 15 revealed wound clinic documentation date of March 14, 2024, which indicated that he had a chronic pressure ulcer on his left buttock measuring 2 centimeters by 2 centimeter by 3 centimeters. Resident 15's current physician order revealed that staff was to place an air mattress to his bed, ensure that it was set at 150 pounds, and provided alternating pressure. Observation of Resident 15 on March 12, 2024, at 10:01 AM revealed that he was in bed and his air mattress was set at 660-750 pounds. Clinical record review for Resident 22 revealed that the facility admitted her on September 25, 2023, with diagnoses of paraplegia (paralyzed lower…

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 the review of facility documentation, four employee files and staff interviews, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of resident tracheostomy, peg tube, and catheter care. Findings include: A review of the facility documentation revealed that the facility had six residents with urinary catheters (insertion of a tube into the bladder to remove urine), one resident with a tracheostomy (a surgical airway management procedure that consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea), and two residents with peg tubes (medical procedure in which a tube is passed into resident's stomach through the abdominal wall, most commonly to provide a means of feeding). A request for nursing staff competencies for tracheostomy, peg tube, and catheter care revealed the facility was unable to provide any. The findings were reviewed with the Nursing Home Administrator and Director of Nursing on…

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

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 and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by four of five residents reviewed (Residents 33, 50, 8, and 75). Findings include: Clinical record review for Resident 33 revealed the facility admitted her on October 22, 2023, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) with other behavior disturbances. A review of Resident 33's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated September 1, 2023, indicated that the facility assessed Resident 33 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 33's care plan revealed that there was no indication that the facility had developed and implemented a…

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

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed and responded appropriately to pharmacy recommendations for four of six residents reviewed (Resident 64, 33, 50, and 75) and failed to ensure that the consulting pharmacy identified potential appropriateness for psychoactive medications for one of six residents reviewed (Resident 64). Findings include: Review of Resident 64's clinical record revealed a physician order dated September 22, 2022, for nursing staff to administer Zoloft (used to treat depression) 150 mg (milligrams) every day for schizoaffective disorder (a combination of symptoms of schizophrenia and bipolar disorder). A consultant pharmacy review dated September 1, 2023, indicated that Resident 64 has been on the current dose of Zoloft since September 2022 and that her physician review the current dose and should consider a gradual dose reduction. There was no documented evidence that Resident 64's physician addressed the consultant pharmacist's recommendation.…

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 a resident's medication regime was free from potentially unnecessary medications for three of five residents reviewed (Residents 2, 8, and 64). Findings include: Clinical record review for Resident 8 revealed current physician orders for Seroquel (for bipolar disorder) 75 milligrams (mg) by mouth (PO) at bedtime (HS), Seroquel 50 mg PO twice daily (BID), Depakote sprinkles (for bipolar disorder) 125 mg two capsules PO daily (QD) and one capsule PO BID, and Duloxetine (for Depression) 60 mg PO QD. Resident 8's physician ordered the every shift staff to monitor her for dry mouth, constipation blurred vision, disorientation/confusion, difficulty urinating, hypotension (low blood pressure), dark urine, yellow skin, nausea and/or vomiting, lethargy drooling, tremors, disturbed gait, increased agitation, restlessness, and/or involuntary movement of the mouth or tongue. Staff were to document Y if monitored and none of the above were observed or N if monitored and any of the above was…

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

Based on clinical record review and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan regarding cognitive loss and psychotropic medication use with behaviors for two of 22 residents reviewed (Resident 64 and 75). Findings Include: Review of Resident 64's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment done at specific intervals to determine care needs) dated May 12, 2023, revealed that the facility assessed Resident 64 as having cognitive loss and determined that a plan of care would be developed to address her cognitive loss. Review of Resident 64's current plan of care revealed that the facility did not develop a plan of care to address her cognitive loss until March 12, 2024. Interview with the Director of Nursing on March 15, 2024, at 9:32 AM, confirmed the above findings for Resident 64. Clinical record review for Resident 75, revealed her current physician orders to include the following psychoactive (medications that affects how the brain works and causes changes in mood, awareness,…

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 select facility policies, clinical record review, and staff and resident interview, it was determined that the facility failed to invite and ensure resident and responsible party attendance and to hold care plan conferences for three of 22 residents reviewed (Resident 8, 62, and 66). Findings include: Clinical record review for Resident 8 revealed that the facility documented a care plan note on February 15, 2023, to review and revise her plan of care. There was no documentation after February 15, 2023, that the facility completed a care plan meeting or invited Resident 8 and/or her responsible party to care plan meetings. Clinical record review for Resident 66 revealed that the facility completed a quarterly MDS MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) on January 16, 2024, and indicated that she was capable. The facility indicated that she was her own responsible party. On October 17, 2023, the facility documented a care plan meeting to review and revise her plan of care with Resident 66 and her…

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 provide services to maintain a resident's range of motion (ROM, movement of the body to maintain a resident's ability) for three of 10 residents reviewed (Residents 69, 66, and 20). Findings include: Interview with Resident 69 on March 12, 2024, at 10:24 AM revealed that he wants to go home. He stated that the staff tell him he needs to be able to walk to be discharged home. Resident 69 indicated that staff do not help him improve his walking. Clinical record review revealed that Resident 69 was discharged from physical therapy on January 5, 2024. Review of the physical therapy discharge summary revealed Resident 69's prognosis was good with consistent staff follow-through. Physical therapy's discharge recommendations included a restorative nursing program to facilitate Resident 69 maintaining his current level of performance and to prevent a decline in his ambulation and transfers. Review of Resident 69's clinical record revealed he was not currently on a restorative nursing program.…

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 thoroughly investigate a resident elopement for one of 22 residents sampled (Resident 44) Findings include: Clinical record review revealed the facility admitted Resident 44 on September 1, 2023. Review of Resident 44's care plan initiated on September 2, 2023, revealed that Resident 44 is a high risk for elopement. Nursing documentation dated December 11, 2023, at 10:59 AM revealed Resident 44 followed a staff member off the locked dementia unit. Documentation revealed staff were alerted by the physical therapist that Resident 44 was on another hall. The physical therapist attempted to get Resident 44 back into the dementia unit when Resident 44 grabbed the handrail in the hallway and would not let go. Documentation revealed that it took three staff members to get Resident 44 back to the dementia unit. The documentation further revealed that Resident 44 was having delusions and was noted to be sitting by the locked door to the unit. Interview with the Nursing Home Administrator,…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of two residents reviewed (Resident 8). Findings include: According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag. Clinical record review for Resident 8 revealed a current physician order for staff to change their oxygen tubing and bag for their CPAP (continuous positive airway pressure, a device to help treat sleep apnea) tubing weekly on Friday during night shift. Observation of Resident 8's Oxygen concentrator on March 12, 2024, at 9:56 AM and March 13, 2024, at 1:51 PM, revealed that their oxygen tubing was dated March 1, 2024 (12 days prior)…

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

Based on clinical record review, resident and staff interview, it was determined that the facility failed to ensure the highest practicable pain management for one of six residents reviewed (Resident 103). Findings include: Clinical record review for Resident 103 revealed that the facility admitted her on January 30, 2024. An admission note dated January 30, 2024, at 3:22 PM, indicated that nursing staff oriented her to the facility and the key locations. There was no documented evidence in the admission note to indicate Resident 103 was experiencing any pain. Review of Resident 103's medication admission orders revealed that she was transferred from the hospital with an order for nursing staff to administer Norco (a combination drug containing acetaminophen and a narcotic pain reliever) 5 mg/325mg (milligrams) one tablet every six hours for moderate to severe pain. Interview on March 12, 2024, at 11:53 AM, with Resident 103 revealed that she had to wait for 59 minutes for a pain pill upon her admission and was in excruciating pain. There was no documented evidence in Resident 103…

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, review of select policies and procedures, and resident and staff interview, it was determined that the facility failed to ensure accurate acquiring and dispensing of medications for one of 22 residents reviewed (Resident 103). Findings include: The policy entitled Remedi, Pharmacy Contact Info, last reviewed on December 4, 2023, indicates that for any new admissions, facility staff must call the pharmacy for any new admissions orders. The pharmacy will not automatically send medications from a facsimile. The policy entitled Medications brought to the facility by the resident last reviewed on December 4, 2023, indicates that if a medication is not available and have been determined to be essential to the resident's life, the Director of Nursing and nursing staff along with the support of the attending physician to ensure that the medication has been ordered by the resident's physician. Review of Resident 103's medication admission orders revealed that she was transferred from the hospital with an order for nursing staff to administer Norco (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 observation and staff interviews, it was determined that the facility failed to prevent the potential spread of infection to one of five residents reviewed for infection control. (Residents 10). Findings include: Observation of Resident 10's door to her room revealed a sign indicating that she was on enhanced barrier precautions. (EBPs, precautions used to prevent the spread of multi-drug resistant organisms). The sign indicated to use gloves and to wear a gown with device care, and listed one example of device care as a tracheostomy ( An opening in the front of the neck with a tube inserted directly into the airway that allows a person to breath). Observation of Resident 10's tracheostomy care on March 14, 2024, at 8:20 AM with Employee 2, LPN (Licensed Practical Nurse), revealed that she performed the care without putting a gown on. Interview with the Director of Nursing on March 14, 2024, at 2:51 PM revealed that Employee 2 should have worn a gown to perform Resident 10's tracheostomy care. The facility failed to prevent the potential spread of a multi-drug resistant…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to perform an assessment for possible entrapment after installation of enabler bars and/or side rails for two of two residents reviewed (Residents 22 and 66). Findings include: Observation of Resident 22 on March 13, 2024, at 9:41 AM revealed that she was in bed sleeping. There was an enabler bar on the left side of her bed. Clinical record review for Resident 22 revealed that she requested the use of enabler(s) on November 10, 2023. There is no documentation indicating that the facility assessed Resident 22's bed to ensure that that the enabler bar placed on Resident 22's bed was compatible with the mattress and/or bed frame utilized and there was no documentation that the facility completed an assessment to ensure that there was not the potential for entrapment while utilizing an enabler bar on Resident 22's bed. Observation of Resident 66 on March 12, 2024, at 11:14 AM revealed that there were bilateral enabler bars on her bed. Clinical record review for Resident 66…

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 provide the highest practicable care regarding physician-ordered treatments for four of five residents reviewed (Residents 1, 2, 4, and 5). Findings include: Clinical record review for Resident 1 revealed a physician's order dated October 7, 2023, for staff to cleanse both skin tears to her right elbow with normal saline solution and apply a bordered dressing every three days. A review of Resident 1's treatment administration record (TAR, a form utilized to document the administration of treatments) dated October 2023, revealed that nursing staff failed to change Resident 1's treatment on October 11, and October 14, 2023. Resident 1's physician discontinued the treatment order on October 16, 2023. Clinical record review for Resident 2 revealed a physician's order dated October 12, 2023, for staff to cleanse the open area on the bottom of Resident 2's left foot, and apply betadine, gauze, and nonadherent dressing every day. A review of Resident 2's TAR dated October 2023, revealed 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.