Birchwood Rehabilitation & Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of select facility policy, and staff interview, it was determined the facility failed to ensure an environment free from potential spread of infection and failed to properly store resident personal care equipment on 2 of 2 nursing units (First Floor and Second Floor).Findings include: A review of the Infection Control Program Policy last reviewed February 9,2026 indicated the infection control program exists to assure a safe, sanitary, and comfortable environment for residents and personnel. It is designed to help prevent the development and transmission of communicable disease and infection. Personal care equipment such as bedpans and graduates may come into contact with bodily fluids. Bodily fluids (such as urine or stool) may contain microorganisms (germs) capable of causing infection. Infection prevention practices require contaminated equipment to be stored in a manner that prevents contamination of clean surfaces and reduces risk of transmission of communicable disease. An…

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

Based on review of the facility's abuse prohibition policy and procedures, report of alleged abuse, clinical record review, and staff interviews, it was determined the facility failed to fully implement its abuse prohibition procedures to identify potential sexual abuse, ensure timely notification of administration and the State Survey Agency, notify the resident's representative and physician, and promptly investigate an allegation of sexual abuse for one of seven sampled residents (Resident 2).Findings include: A review of the facility policy titled Abuse Policy last reviewed by the facility on August 14, 2025, revealed all allegations of abuse must be reported immediately to the Director of Nursing (DON). In the absence of the Director of Nursing such reports may be made to the Nurse Supervisor on duty. The Nursing Home Administrator (NHA) or Director of Nursing must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the NHA and DON must be called at home or must be paged and informed. The facility's abuse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, select facility policy, and staff interviews, it was determined that the facility failed to implement individualized, person-centered interventions identified in the care plan to address dementia-related behaviors for one of seven sampled residents (Resident 4). Findings include: A review of a facility policy for Dementia-Clinical Protocols, reviewed August 2025 revealed, for residents with a confirmed dementia diagnosis, the interdisciplinary team will develop and implement a resident-centered care plan designed to maximize remaining function and quality of life. Clinical record review revealed that Resident 4 was admitted to the facility on [DATE], with diagnosis to include dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems). A quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 3, 2025, 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 a review of clinical records, select investigative reports, and employee job descriptions and staff interview it was determined the facility's administration, Nursing Home Administrator and Director of Nursing, failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental functioning of residents in the facility by failing to monitor one resident's whereabouts and prevent an elopement for one (Resident 3) out of 5 sampled residents and failed to ensure the safety and supervision of a resident who lacked decision-making capacity and required protective oversight, allowing the resident to exit the building, placing the resident at risk for serious harm (Resident2) which created an Immediate Jeopardy situation. Findings included: A review of the job description for the Administrator dated October 7, 2024 revealed the administrator must be knowledgeable of and demonstrate the ability to provide quality care by fostering a safe environment for residents and staff; providing emotional and psychological support for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an effective, individualized, person-centered care plan to address a resident's dementia-related behavioral symptoms for one of 5 residents reviewed (Resident 1).Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia (a progressive condition involving cognitive decline, memory loss, and changes in personality and behavior) and anxiety disorder (a mental health condition characterized by persistent worry or fear that interferes with daily functioning). A quarterly Minimum Data Set (MDS an assessment completed periodically to plan resident care) dated June 23, 2025, indicated that Resident 1 was moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status a tool to assess the resident's attention, orientation, and the ability to register and recall new information, a score…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, select facility policy, and staff interview it was determined the facility failed to evaluate nutrition and hydration requirements to ensure acceptable parameters of nutritional status and hydration status to the extent possible for one resident out of 12 sampled (Resident A1). Findings include: Review of the facility Nutritional Assessment Policy last reviewed March 13, 2025, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components: usual body weight, current weight and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, select facility policy, observation, and staff interview, it was determined the facility failed to obtain physician orders for oxygen therapy and failed to maintain oxygen equipment in a functional and sanitary manner for four residents out of 23 sampled (Residents 6, 56, 60 and 68). Findings include: Review of the facility policy titled Departmental (Respiratory Therapy)-Prevention of Infection last reviewed by the facility on March 3, 2025, revealed that the oxygen cannula (flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen) and tubing are to be changed every seven days, or as needed. The oxygen cannula and tubing used PRN (as needed) are to be kept in a plastic bag when not in use. The oxygen concentrator (bedside machine that concentrates ambient air to supply an oxygen-rich gas stream) filters are to be washed every seven days with soap and water, then rinsed and squeezed dry. Review of Resident 56's clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the Resident Assessment Instrument (RAI) Manual, clinical record review, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments were submitted to the Centers for Medicare & Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system within the required 14-day timeframe for 2 of 23 residents reviewed (Residents 41 and 45). Findings include: According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, version dated October 2019, federally mandated MDS assessments (mandated assessments of a resident's abilities and care needs) must be submitted within 14 calendar days after the MDS Completion Date (Section Z0500B + 14 days). Additionally, discharge tracking records must be completed and transmitted within 14 calendar days following the Event Date (Section A2000 + 14 days). A review of Resident 41's clinical record revealed a quarterly MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one out of 23 residents sampled (Resident 49). Findings included: A review of Resident 49's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included end stage kidney disease (is a condition where the kidney reaches advanced state of loss of function that causes changes in urination, fatigue, swelling of feet, high blood pressure, and loss of appetite) and required hemodialysis (a machine filters wastes, salts and fluid from the blood when the kidneys are no longer healthy enough to do this work adequately and used to treat advanced kidney failure) three times per week. A review of Resident 49's quarterly review MDS assessment dated [DATE], revealed in Section O - O0011.0 Special…

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 the facility failed to develop and implement a baseline care plan that included the minimum healthcare information necessary to address the resident's immediate care and safety needs upon admission for one of 23 residents reviewed (Resident 318). Findings: A review of Resident 318's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including osteomyelitis (an infection in a bone) and diabetes mellitus (a metabolic disorder in which the body has elevated blood sugar levels for prolonged periods of time). A review of a social services progress note dated March 30, 2025, at 5:15 PM, indicated that Resident 318 did not speak English very well. Further review of Resident 318's baseline care plan revealed it failed to identify English as a second language as part of the resident's communication needs. Additionally, the baseline care plan failed to include measurable goals, objectives, or interventions to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on select facility policy, a review of clinical records and resident and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses timely administered a resident's medications for one resident of 23 reviewed (Resident 56). Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and staff interviews, it was determined the facility failed to ensure a timely and thorough assessment of pressure ulcers/injuries upon admission for one of 23 sampled residents (Resident 39). Findings included: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, select policy review, a review of clinical records, and staff interview it was determined the facility failed to provide care and services designed to prevent potential complications associated with tube feedings for one resident receiving an enteral feeding out of 23 residents sampled (Resident 58). Findings include: Review of a facility policy titled Enteral Feedings - Safety Precautions last reviewed by the facility on March 3, 2025, indicated that all personnel responsible for preparing , storing and administering enteral nutrition (tube inserted through the abdomen directly into the stomach, used to deliver nutrition, fluids, and medications when a person cannot eat or drink safely or consume enough calories orally) formulas will be trained, qualified and competent and that the facility will remain current in and follow accepted best practices in enteral nutrition. Further it indicated that to prevent aspiration (occurs when food or liquid enters the lungs instead of the stomach,…

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 and select facility policy review and staff interview, it was determined that the facility failed to provide effective pain management and administer pain medication as prescribed by the physician and failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for one resident out of four residents sampled for pain (Resident 114). Findings include: Review of the facility policy titled Pain Assessment and Management, last reviewed by the facility on March 3, 2025, revealed non-pharmacological interventions may be appropriate alone or in conjunction with medications to manage pain. Examples of non-pharmacological interventions included environmental adjustments (such as adjusting room temperature or providing pressure-reducing surfaces), physical interventions (such as ice packs or warm compresses), exercise (such as range of motion exercises), and cognitive or behavioral strategies (such…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of clinical records, resident and staff interviews, it was determined the facility failed to provide sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as evidenced by one resident out of 21 sampled (Resident 97). Findings include: Review of the facility policy titled Behavioral Assessment, Intervention, and Monitoring last reviewed March 3, 2025, indicated the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Furthermore, if the resident is being treated for altered behavior or mood, the interdisciplinary team will seek and document any improvements or worsening…

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 record review and staff interview, the facility failed to ensure that a PRN (as-needed) psychotropic medication was limited to 14 days without a documented physician rationale for extension and failed to document the use of non-pharmacological interventions prior to administering a PRN antianxiety medication, for Resident #39. Findings include: A review of Resident 39's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of the bladder (another term for bladder cancer, is a common type of cancer that begins in the cells of the bladder), malnutrition (is the condition that develops when the body is deprived of vitamins, minerals and other nutrients it needs), and anxiety disorder (a mental health conditions that cause excessive fear and worry in response to situations). A review of Resident 39's physician orders revealed an order dated February 6, 2025, at 11:50 AM, for Ativan (lorazepam a benzodiazepine that work by enhancing…

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 the facility's Medication Storage and Labeling policy, observations, manufacturer's instructions, and staff interviews, it was determined that the facility failed to ensure medications and biologicals were stored and labeled in accordance with professional standards and manufacturer recommendations. Specifically, the facility failed to ensure that opened multi-dose medication vials were labeled with an open date and failed to ensure that expired intravenous (IV) supplies were not available for resident use on two of two nursing areas (First Floor Nursing Unit and First Floor Medication Room). Findings include: Review of the facility Medication Storage and Labeling policy last reviewed [DATE], indicated that medications and biologicals (medications that come from living organisms) are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Multi dose vials which have been opened or accessed (e.g., needle puncture) should be dated and discarded…

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 reviews and staff interviews, it was determined the facility failed to ensure that a dependent resident was provided with the necessary services to maintain personal hygiene by failing to provide showers as scheduled for one of six residents sampled (Resident CR1). Findings include: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], and had diagnoses, which included dementia (the loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and a fracture of the right foot. The resident was discharged from the facility to home on December 16, 2024. A review of the resident's shower record revealed the resident was to be showered on Tuesdays and Fridays on the 3:00 PM to 11:00 PM shift. A review of the resident's shower schedule for the dates of November 26, 2024, through December 16, 2024, revealed the resident received a bed bath on November 26, November 29, 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 review of select facility policy and clinical records, and staff interview it was determined the facility failed to timely monitor the nutritional parameters of a resident with an identified significant weight loss for one of six residents sampled (Resident CR1). Findings include: Review of the facility Weight Assessment and Intervention Policy last reviewed March 4, 2024, indicated that residents are monitored for undesirable or unintended weight loss or weight gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team. Weights are recorded in each unit's weight record chart and in the individual's medical record. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. The threshold for significant unplanned and undesired weight loss will be based 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 a review of clinical records, select facility policy, observations and staff interview it was determined the facility failed to ensure the resident environment was free from potential accident hazards for two out of two nursing units observed (100 and 200 halls). Findings included: A review of facility policy titled Self-Administration of Medications, last revised February 2021, revealed residents have the right to self-administer medication if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The policy indicates that if it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces). During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment in one of the two nursing halls (First floor nursing unit). Findings include: An observation on October 24, 2024, at 11:00 AM, in room [ROOM NUMBER] revealed food, dirt, and debris on the floor around and under the resident's bed. The floor was noted to be sticky. During an interview on October 24, 2024, at the time of the observation Resident 2 was asked how often her floor is swept and mopped. The resident replied, not too often, once in a blue moon. An observation on October 24, 2024, at 11:10 AM, in room [ROOM NUMBER] revealed the floor was dirty with dirt and paper debris. Further it was noted the garbage can overflowing with trash. An observation on October 24, 2024, at 11:15 AM, in room [ROOM NUMBER] revealed the floor was dirty with dirt and paper debris. The tube feeding pole in the room had dried tube feeding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, observations and staff and resident interviews it was determined that the facility failed to provide planned care and services, consistent with professional standards of practice to treat pressure sores and prevent worsening for one resident out of 19 sampled (Resident 32). Findings included: A review of Resident 32's clinical record revealed that the resident was initially admitted to the facility on [DATE], with diagnoses to have included a cerebral infarction [occurs when the blood supply to part of the brain is blocked or reduced, which prevents brain tissue from getting oxygen and nutrients that result in brain cells dying], vascular dementia [is a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain], congestive heart failure [(CHF) is a long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply 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 clinical record and select policy review, and staff interview it was determined that the facility failed to provide care and services designed to prevent potential complications with enteral tube feedings for one resident receiving an enteral feeding out of 19 residents sampled (Resident 56). Findings include: Review of a facility policy entitled Enteral Feeding provided by the facility on June 6, 2024, indicated that the facility will provide adequate nutritional support through enteral nutrition as ordered. According to the policy, staff caring for resident with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube, such clogging of the tube. Review of Resident 56's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included dysphagia (difficulty swallowing), epilepsy (neurological condition involving the brain that makes people more susceptible to having recurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined that the attending physician failed to act upon pharmacist identified irregularities in the medication regimen of one of 19 residents sampled (Resident 46). Findings include: A review of the clinical record revealed Resident 46 was admitted to the facility on [DATE], and had diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and bipolar disorder. A review of February 2024 monthly pharmacy reviews revealed that the consultant pharmacist noted that the resident was prescribed as needed Ativan .5 mg for anxiety. Noting that per CMS guidelines all PRN psychotropic agents must be limited to a 14-day duration. This resident currently has an active PRN order for Lorazepam that requires change to meet these regulations. The facility failed to provide written documentation of the attending…

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, a review of temperature logs and staff interview it was determined that the facility failed to store drugs and pharmacy supplies under proper temperatures (2nd Floor Medication Room) and adhere to expiration/use by dates in one medication storage rooms out of two medication storage rooms. Findings include: Review of facility provided document entitled Temperature Log for Refrigerator indicated that medications and vaccines requiring refrigeration storage should be stored at a temperature range of 35 degrees Fahrenheit to 46 degrees Fahrenheit. An observation of the 2nd Floor Medication Storage Room sink on June 6, 2024, at 8:52 a.m., revealed that there was a white putty-like substance smeared inside. Observation of the 2nd Floor Medication Storage Room refrigerator revealed that the initial temperature reading on June 6, 2024, at 8:56 a.m., was at 28 degrees Fahrenheit and was below the acceptable temperature range 36 - 46 degrees Fahrenheit for medication storage. The freezer compartment had an accumulation of ice crystals covering the surface. Observations…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility's abuse prohibition policy, clinical records, information submitted by the facility, and select investigative reports and staff interview it was determined that the facility failed to assure that one resident (Resident B2) out of four sampled was free from physical abuse perpetrated by another resident (Resident B1). Findings included: A review of the current facility policy titled Abuse Policy, provide by the facility on May 17, 2024, revealed it is the policy of the facility that the residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. As part of the resident abuse prevention program, the administration will protect the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview it was determined that the facility failed to develop a person-centered comprehensive plan of care to meet the specific supervision needs of one resident out of 12 sampled (Resident B1). Findings included: A review of Resident B1's clinical record revealed admission to the facility on March 18, 2024, with diagnoses to include cerebral infarction (brain damage that results from a lack of blood), vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to parts of the brain, depriving them of oxygen and nutrients), and cognitive communication deficit. An admission MDS dated [DATE], indicated that the resident was severely cognitively impaired with a BIMS score of 3 (0-7 represents severe cognitive impairment). A review of ACT-13 Mandatory Abuse Report dated March 19, 2024, at 1:45 PM revealed Resident B1 was sitting in the hall when he reached over and touched a female resident's face with his right hand while…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policy, clinical records and documentation and staff interviews, it was determined that the facility failed to demonstrate the implementation of ongoing QAPI programs, to include the use of systems for investigating and analyzing the root cause of adverse events as evidenced by one resident out of 12 sampled (Resident A1). Findings include: Review of the facility policy entitled Quality Assurance/Performance Improvement last reviewed March 1, 2024 revealed, the facility shall develop, implement and maintain an ongoing, facility wide data driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The objectives of the QAPI program are to: 1. provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. provides a means to establish and implement performance improvement projects to correct identified negative and problematic indicators. 3. reinforce and buildup effective systems and…

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

Based on a review of select facility policy, the minutes from Resident Council meetings, and grievances lodged with the facility, and resident and staff interviews, it was determined that the facility failed to demonstrate sufficient efforts to respond and resolve resident and/or family complaints that includes concerns expressed during Resident council, including those voiced by eight residents. (Resident 1, 8, 13, 14, 15, 16, CR2 and CR6) The findings include: A review of facility policy entitled Grievance Policy last updated by the facility April 30, 2023, revealed that all grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within (5) working days or receiving the grievance and/or complaint. The resident, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and facility documentation, and staff, resident and family interview, it was determined the facility failed to develop operational policies and procedures, and follow CMS (Center for Medicare and Medicaid Services) guidance to protect the resident from unacceptable practices of disenrolling residents from the Medicare Advantage Plans by ensuring all risks of disenrolling are explained and the residents are competent in making the informed decision for nine of 20 reviewed (Resident 9, 10, 11, 12, CR3, CR4, CR5, CR6, and CR7). Finding include: A review of a CMS guidance entitled Memo to Long Term Care (LTC) Facilities on Medicare Health Plan Enrollment dated October 2021 revealed CMS continues to hear reports of the unacceptable practice of nursing facilities or skilled nursing facilities (collectively, long-term care or LTC facilities) disenrolling beneficiaries from Medicare health plans (Medicare Advantage plans with and without Part D, Medicare-Medicaid plans, or Programs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, it was determined that the facility failed to maintain a clean and orderly environment in resident areas on one of two resident care units. (first floor) Findings included: An observation on March 28, 2024, at approximately 8:30 AM of the first floor revealed peeling/chipped paint on the windowsills at the end of each hallway. Missing and peeling paint was observed on the multiple resident room doors on this unit. At end of the hallway on the first floor unit, floor tiles were missing and broken and a large area of molding was missing, exposing the drywall. An observation of resident room [ROOM NUMBER] revealed stained ceiling tiles. In resident room [ROOM NUMBER], laminate was missing on the surfaces of the drawers by the sink. Soiled linens were observed on the floor and draped over the wheelchair, in Resident room [ROOM NUMBER] Interview with the Director of Nursing on March 28, 2024, at approximately 1:45 PM confirmed that the facility is required to provide…

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 reviews and staff interviews, it was determined that the facility failed to ensure that dependent residents were provided with the necessary services to maintain good personal hygiene, by failing to provide showers as scheduled for two of 20 residents sampled (Residents 3 and 12). Findings include: A review of the clinical record revealed that Resident 3 was admitted to the facility on [DATE], and had diagnoses, which included a need for assistance with personal care and other abnormalities of gait and mobility. A review of the resident's shower record revealed that the resident was to be showered on Tuesdays and Thursdays on the 7:00 AM to 3:00 PM shift. A review of the resident's shower schedule for the month of January 2024 and February 2024 revealed that the resident was showered once in two months and given a bed bath twice in these two months. There was no documented evidence in the resident's clinical record or care plan of any resident refusals or reasons for not showering this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, information submitted by the facility, and select facility reports and staff interviews, it was determined that the facility failed to provide necessary supervision and effective safety measures to monitor the whereabouts and activities of one resident at risk for elopement (Resident 2) and failed to implement appropriate interventions based on individual needs of a resident at increased risk for falls to promote resident safety and prevent falls for one resident (Resident 3) out of 20 sampled. Findings include: A review of the clinical record revealed that Resident 2 was originally admitted to the facility on [DATE], with diagnoses of Dementia (a group of symptoms that affects memory, thinking, and interferes with daily life). Review of Resident 2's plan of care, dated as initiated June 7, 2023, revealed that the resident was identified as a high risk for elopement due to exit seeking behavior with planned interventions to calmly redirect an divert resident's attention,…

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

Based on observations and staff interview, it was determined that the facility failed to maintain infection control practices to prevent spread of infection for one of 20 sampled residents. (Resident 5) Findings include: Observation of Resident 5's room on March 28, 2024, at approximately 8:30 AM revealed that there were several unopened sterile 4 x 4 gauze packages on the resident's nightstand. An opened 1000 mL bottle of Sterile water and an uncovered 60 mL piston syringe used for irrigation, were also on the nightstand. Approximately 200 mL was remaining in the bottle and was not dated. Additional observation of Resident 5's room revealed an opened tube of silver antibacterial wound gel between the foot of the mattress and the footboard of the bed. During observation, Resident 5 stated that the nurse must have left it there after doing my leg. Resident 5's indwelling urinary catheter drainage bag was also observed hanging on the side of the bed, yet the catheter bag drainage tube was resting directly on the floor. During an interview with the Nursing Home Administrator and…

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

Based on staff interview and a review of employee credentials, it was determined that the facility failed to employ a full-time qualified dietary services supervisor in the absence of a full-time qualified dietitian. Findings include: Interview with the facility's Nursing Home Administrator on August 8, 2023, at approximately 3 PM, revealed that Employee 1 became the dietary supervisor on January 13, 2023. The NHA also verified that Employee 1 was not possess the regulatory required qualifications, and was not a CDM (certified dietary manager), but was in the process of completing the CDM program. The NHA confirmed that Employee 1 (dietary manager) was enrolled in a CDM program, however was unable to state when the program would be completed and when she would test obtain certification. The NHA also stated that the full time Registered dietitian resigned the position on June 30, 2023. She confirmed that the facility did not have an in house Dietitian since the former RD resigned. She stated that all the dietary documentation from June 30, 2023 to the date of the survey was completed…

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 provide an enteral feeding formula prescribed for one resident out of two sampled (Resident 1). Findings include: Clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include multiple sclerosis ( a progressive neurological disease). A review of an annual Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated July 13, 2023, revealed Resident 1 was cognitively intact, required staff assistance for activities of daily living, and received nutrition through a gastric tube (g-tube, a rubber tube surgically inserted into the stomach for receiving liquid nutrition as well as liquefied medication). The resident had a current current physicians order initially dated September 26, 2022 for Vital (an enteral feeding) 1.5, 237 mls 5 times a day via the peg tube. During an…

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

Based on review of controlled drug records and select facility policy and staff interview, it was determined that the facility failed to implement procedures to promote accurate controlled medication records and failed to ensure medication availability for one of 8 residents sampled (Resident 1) . Finding include: A review of the clinical record revealed that Resident 1 had a current physician orders dated May 31, 2023, for Oxycodone (a narcotic opioid pain medication) 5 mg Tablet, via the peg tube ( a rubber tube surgically inserted into the stomach ) every 4 hours, as needed for moderate pain. A review of the controlled substance record accounting for the above narcotic medication revealed that on: June 2, 2023 at 10:30 P.M. June 4, 2023 at 10:30 P.M, June 5, 2023 at 2 P.M, June 5, 2023 at 10 P.M., June 8, 2023 at 10 P.M., June 9, 2023 at 2 P.M., June 10, 2023 at 2 P.M. June 13, 2023 at 10 P.M., June 15, 2023 at 1:45 P.M., June 15, 2023 at 10:30 P.M., June 16, 2023 at 10:30 P.M. June 17, 2023 at 9 P.M., June 18, 2023 at 9 P.M., June 19, 2023 at 10:30 P.M. June 20, 2023 at 10:30…

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, select facility review and staff and resident interview, it was determined that the failed to reassess a resident's pain and repeated daily use of opioid pain medication prescribed on an as needed basis to ensure effective individualized pain management plans are developed and implemented for one of 8 residents sampled (Resident 1). Findings include: Clinical record revealed that Resident 1 was admitted to the facility on [DATE] with diagnosis to include multiple sclerosis (a progressive neurological disease) muscle spasms and chronic pain. Resident 1 had current physician orders dated May 31, 2023, for Oxycodone (a narcotic opioid pain medication) 5 mg Tablet, via the peg tube ( a rubber tube surgically inserted into the stomach ) every 4 hours, as needed for moderate pain. A review of an annual Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated July 13, 2023, revealed 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.