Lakewood Rehabilitation & Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure the pharmacist conducted medication regimen reviews at least monthly for one resident out of five reviewed (Resident 42).Findings include: A review of a facility policy entitled Medication Regimen Reviews, last reviewed by the facility on January 1, 2026, indicated the facility's consultant pharmacist reviews the medication regimen review (MRR) for every resident in the facility at least monthly. The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and re-solve medication-related problems, medication errors, and other irregularities, for example, medications ordered in excessive doses or without clinical indication; medication regimens that appear inconsistent with the resident's stated preferences; duplicative therapies or omissions of ordered medications; inadequate monitoring for adverse consequences; potentially significant drug-drug…

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 select facility policy, clinical records, and a staff interview, it was determined the facility failed to offer pneumococcal immunization in accordance with facility policy and current Centers for Disease Control and Prevention (CDC) recommendations, unless medically contraindicated or the resident had already been fully immunized, for one of five residents reviewed (Resident 81).Findings include: A review of facility policy titled Pneumococcal Vaccine, reviewed by the facility on January 1, 2026, revealed that it is the facility's policy to offer pneumococcal vaccines (vaccines that protect against infections caused by Streptococcus pneumoniae, including pneumonia, bloodstream infections, and meningitis) to aid in preventing pneumonia or pneumococcal infections. The policy indicated the administration of pneumococcal vaccines or re-vaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination. A review of CDC…

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, employee personnel records, facility policies and procedures, and staff interviews, it was determined the facility failed to develop, implement, and maintain an effective training program to ensure licensed nursing staff possessed the knowledge and competencies necessary to safely manage a peripherally inserted central catheter (PICC line) for two of 22 residents reviewed (Residents 1 and 30).Findings include: Federal regulation requires a facility to develop, implement, and maintain an effective training program for all new and existing staff. The training program must be based on the facility assessment (an evaluation conducted by the facility to identify the resident population and determine the knowledge and skills staff need to meet resident care needs). Pennsylvania State Board of Nursing Regulations (Title 49, Chapter 21) requires licensed nurses performing intravenous therapy, including care involving PICC lines, complete appropriate education, receive supervised…

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, and staff interviews, it was determined the facility failed to implement procedures to ensure the timely acquisition and administration of a prescribed medication to one of four sampled residents (Resident CR1).Findings include: A review of the facility policy titled Unavailable Medication, last reviewed by the facility on December 8, 2025, revealed it is the facility policy that, in conjunction with the contracted pharmacy, the facility will make every effort to ensure that a medication ordered for the resident is available to meet their needs. Upon receipt of information from the pharmacy regarding a medication that is unavailable, nursing staff shall notify the physician, obtain a new order and discontinue the prior order, or obtain a hold order for the unavailable medication. A clinical record review revealed resident CR1 was admitted to the facility on [DATE], with diagnoses that included cellulitis of the right lower limb (a skin infection…

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, information submitted by the facility, the facility's abuse prohibition policy and staff interviews, it was determined the facility failed to accurately and completely report and document an alleged incident of sexual abuse for 1 of 8 residents reviewed (Resident 1) to the State Survey Agency and the Area Agency on Aging. Findings include: A review of facility policy entitled Abuse Protection last reviewed by the facility on December 8, 2025, revealed under the category Reporting Serious crimes, it is the facility's responsibility to report any occurrences of abuse, neglect, misappropriation of resident property, and suspicions of a crime to the State Survey Agency, Department of Aging and local law enforcement. The policy further revealed if the reportable event resulted in serious bodily injury (sexual abuse), the facility is to report the event within 2 hours of forming the suspicion. A review of a facility policy entitled Identifying Sexual Abuse and Capacity to Consent…

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 facility policies, documentation provided by the facility, and interviews with residents and staff, it was determined that the facility failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental well-being of residents in accordance with federal requirements. Specifically, the facility's administration failed to ensure that one of eight residents sampled (Resident 1) was free from sexual abuse perpetrated by another resident (Resident 2). This failure resulted in Immediate Jeopardy to resident health and safety.Findings included: A review of the job description for the Nursing Home Administrator (NHA) signed and dated August 19, 2024, revealed the administrator will 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 residents within the facility, directing, and overseeing the day-to-day operation of the facility to ensure that the highest…

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 policies, clinical record review, review of facility-provided documentation, and staff interviews, it was determined that the facility failed to protect and maintain personal privacy and dignity when staff recorded a resident receiving incontinence care without consent. This failure resulted in a violation of personal privacy protection for 1 of 5 sampled residents (Resident 1). This concern represents past non-compliance, as the facility identified, addressed, and corrected the issue before the survey.Findings include: A review of a select facility policy for Use of Employee Telephones, last reviewed December 8, 2025, revealed it is the policy of the facility that cellular phones may be used for personal calls and text messaging only when the employee is on authorized meal and break periods, and employees' cell phones will remain off or on silent during all other work hours. A review of a select facility policy for Dignity, last reviewed December 8, 2025, revealed it is 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, and interviews with residents and staff, it was determined the facility failed to conduct care plan conferences and failed to ensure that residents were invited to participate in the care planning process for three of 20 residents reviewed (Residents 16, 51, and 85). Findings include: Review of the facility Care Planning- Interdisciplinary Team Policy last reviewed May 1, 2025, indicated the interdisciplinary team (IDT) is responsible for resident care plans. The IDT includes but is not limited to the resident's attending physician, a registered nurse with responsibility for the resident, a nursing assistant with responsibility for the resident, a member of the food and nutrition staff, to the extent practicable the resident and/or the resident's representative, and other staff as necessary to meet the needs of the resident, or as requested by the resident. Care plan meetings are scheduled at the best time of the day for the resident and family when possible. If…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to implement procedures to ensure the timely acquisition and administration of prescribed medications for three of 20 sampled residents (Residents 49, 78, and 82). Findings include: A review of facility policy labeled Medication Process- Medications Unavailable last reviewed May 1, 2025, revealed the Licensed nurse is to check the Med Cubex (a pharmacy inventory management system) Inventory on Hand first. If a medication is identified as not being available in the Cubex, the Licensed nurse is to call the pharmacy to determine the medication deliver status. Following the information received from the pharmacy, the licensed nurse is to call the physician with the information on the medication delivery status and request a new order for medication administration if the medication will not be available to be administered. An interview with the Director of Nursing (DON) and the clinical nurse…

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 and resident and staff interviews, it was determined the facility failed to ensure that fresh drinking water was consistently readily accessible to residents to promote adequate hydration, meet resident preferences, and maintain their comfort for five of 20 residents reviewed (Residents 22, 5, 196, 76, and 83). Findings include: A review of the facility policy titled Serving Drinking Water last reviewed by the facility on May 1, 2025, indicated the facility will provide a fresh supply of drinking water. During a resident group interview on June 11, 2025, at 10:00 AM, five of five alert and oriented residents in attendance (Residents 22, 5, 196, 76, and 83) voiced concerns that fresh ice water was only consistently provided during the overnight shift (11:00 PM to 7:00 AM) and not during the day or evening shifts unless residents specifically requested it. Resident 22 stated that she enjoys drinking fresh ice water but is not provided with fresh water during the day or evening unless she asks staff to provide it. Resident 5 stated that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based clinical record review and interview with staff, it was determined the facility failed to provide the right to communication with and access to persons and services outside the facility for one resident out of 20 sampled (Resident 51). Findings Include: A clinical record review revealed Resident 51 was admitted to the facility on [DATE], with diagnosis to include a hereditary ataxia (a group of genetic disorders characterized by progressive problems with coordination and balance (ataxia) that are inherited from one generation to the next. These conditions affect the nervous system, particularly the parts of the brain responsible for motor control, such as the cerebellum, spinal cord, and peripheral nerves) and muscle weakness. A review of the quarterly Minimum Data Set Assessment ( MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 14, 2025, revealed the resident was moderately cognitively impaired with a BIMS score of 12 (Brief Interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy, and staff interviews, it was determined that the facility failed to provide prescriptions for physician-ordered medications at the time of discharge to ensure a safe and orderly transition to home for one resident out of four closed records reviewed (Resident 146). Findings include: Review of the facility Discharge Summary and Plan Policy last reviewed May 1, 2025, indicated that when a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge. The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's current diagnosis, medical history, course of illness, treatment and/or therapy since entering…

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 the Resident Assessment Instrument (RAI) and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 20 sampled (Resident 19). Findings included: A review of Resident 19's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from disease of the brain). A review of Resident 19's quarterly MDS assessment dated [DATE], revealed in Section P0100, Physical Restraints, Resident 19 required a limb restraint used in chair or out of bed documented as Code 1 indicating the device was used less than daily. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, observation, and staff interviews, it was determined the facility failed to follow the comprehensive care plan by not ensuring the consistent application of preventative measures for fall safety for one of 20 residents sampled (Resident 50). Findings include: A review of the facility policy titled Falls-Clinical Protocol, last reviewed by the facility on May 1, 2025, revealed that based on the fall assessment for the resident, the staff and physician will identify pertinent interventions to try to prevent subsequent falls to address risks of serious consequences of falling. A review of the clinical record revealed Resident 50 was admitted to the facility on [DATE], with diagnoses to include liver cancer (a disease in which abnormal cells divide uncontrollably and destroy body tissue) and major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility documentation and select facility policies and procedures and staff interview, it was determined that the facility failed to provide nursing services, which met professional standards of quality according to Title 49, Professional and Vocational Standards Chapter 21 State Board of Nursing during medication transcription and medication administration resulting in a medication error for one of 22 residents reviewed. (Resident 3)Findings include: According to Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all the following functions: (4) Carries out nursing care actions which promote, maintain and restore the well-being of individuals (6)(b) The registered nurse is fully responsible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and resident and staff interviews, it was determined that the facility failed to ensure one resident dependent on staff for assistance with activities of daily living (ADLs) consistently received showers as planned to maintain personal hygiene for one of 20 sampled residents (Resident 85). Findings include: A review of Resident 85's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include spinal cord compression (pressure on the spinal cord causing numbness, pain, weakness and loss of bowel and bladder control), muscle weakness, and need for assistance with personal care. A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 14, 2025, indicated the resident required substantial/maximal assistance from staff for showering/bathing. The resident was cognitively intact with a BIMS score of 15 (brief interview for mental status, 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 a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility for one resident out of 20 residents sampled (Resident 8). Findings include: Review of the facility Restorative Nursing Services Policy, last reviewed May 1, 2025, revealed that residents will receive restorative nursing care as needed to help promote optimal safety and independence. Further review of the policy revealed that the resident's restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. A review of the clinical record for Resident 8 revealed the resident was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and generalized muscle weakness. A quarterly Minimum Data Set…

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, observation, and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered per physician's orders for one resident out of 20 sampled (Resident 16). Findings include: A review of the facility Oxygen Administration Policy last reviewed May 1, 2025, revealed the purpose of the facility policy is to provide guidelines for safe oxygen administration. The policy indicates to verify there is a physician's order for oxygen administration and document the rate of oxygen flow, route, and rationale. A clinical record review revealed that Resident 16 was admitted to the facility on [DATE], with diagnosis to include respiratory failure (serious condition that makes it difficult to breathe). A physician order dated May 7, 2025, noted an order for oxygen 4 liters/minute via nasal cannula every shift for a diagnosis of COPD (chronic obstructive pulmonary disease- a group of lung diseases that cause airflow obstruction 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 select facility policy, clinical records, and staff interview, it was determined the facility failed to ensure pneumococcal and influenza immunizations were offered and/or provided, unless medically contraindicated or previously administered, for one of five residents reviewed (Resident 6). Findings include: A review of facility policy titled Pneumococcal Vaccine last reviewed May 1, 2025, revealed prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine. When indicated, the vaccine will be offered and be administered within 30 days of admission. Assessments of pneumococcal vaccination status are conducted within five working days of the resident's admission if not conducted prior to admission. A review of facility policy titled Influenza Vaccine last reviewed May 1, 2025, revealed that all residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote 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 select facility policy, clinical records, information submitted by the facility, select investigative reports, and staff interviews, it was determined the facility failed to conduct a thorough investigation into allegations of potential resident-to-resident abuse for one resident out of 12 sampled (Resident 2) perpetrated by another resident (Resident CR1). Findings include: A review of facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, last reviewed by the facility on July 21, 2024, revealed it is the facility policy that residents have the right to be free from abuse, neglect, and exploitation. The policy indicates this includes but is not limited to freedom from corporal punishment, involuntary seclusion, and verbal, mental, sexual, or physical abuse. The policy indicates the abuse prevention program consists of a facility-wide commitment to protect residents from abuse, neglect, and exploitation by anyone, including other residents. Further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and resident and staff interviews, it was determined the facility failed to provide pharmaceutical services for acquiring medication to meet the needs of two of the five residents sampled (Residents 1 and 2) and failed to implement procedures to promote accurate accounting of narcotic medications for one of the five residents sampled (Resident 1). Findings include: A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included osteoarthritis (a chronic joint disease that causes the breakdown of cartilage). A review of an admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 16, 2025, revealed Resident 1 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall…

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 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 (Resident 1) and prevent an elopement for one out of 6 sampled residents. Findings included: Based on review of clinical records and select facility policy, and staff and resident interviews it was determined the facility failed to provide necessary supervision and effective safety measures to monitor a resident's whereabouts and prevent an elopement for one resident (Resident 1) out of 6 sampled residents This failure placed 8 out of 99 residents residing in the facility, identified at risk for elopement, in immediate jeopardy to their health and safety. A review of the job description for the Administrator dated August 19, 2024 revealed the administrator must be knowledgeable of and demonstrate the ability…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of facility documentation, the facility failed to provide quality care by not timely responding to Resident 1's change in condition, including the failure to implement appropriate interventions or timely transfer the resident to a higher level of care for one of 5 residents reviewed. (Resident 1). Findings include: Clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses including muscle weakness and hypertension. The resident was her own responsible party, as documented on admission, with no designated representative or power of attorney. A Quarterly Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated [DATE], revealed a BIMS score of 10 (Brief Interview for Mental Status (BIMS) calculator checks the resident cognitive impairment, a score of 8-12 indicates moderate, cognitive impairment) and required assistance…

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

Based on clinical record reviews and staff interviews, it was determined the facility failed to ensure provision of a written notice for a facility-initiated transfer to the hospital. Specifically, the facility failed to provide a written notice regarding the reason for the transfer to the resident and the resident's representative in a language and manner easily understood, for one resident out of 6 residents sampled (Resident 2). Findings include: A review of the clinical record revealed that Resident 2 was transferred to the hospital on December 29, 2024, due to a change in mental status and had not returned to the facility as of the conclusion of the survey on December 30, 2024. Documentation related to the transfer indicated that the transfer was facility-initiated; however, there was no evidence that a written notice was provided to the resident or the resident's representative explaining the reason for the transfer in a language and manner that was easily understood. During an interview with the Nursing Home Administrator (NHA) on December 30, 2024, at approximately 2:00 PM,…

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

Based on a review of clinical records, the facility's bed-hold policy, and staff and family interviews, it was determined the facility failed to provide written notice of the specifics of the facility's bed-hold policy, including the duration and reserve bed payment policy, to a resident's representative upon the resident's transfer to the hospital for one of six sampled residents (Resident 2). Findings include: A review Resident 2's clinical record revealed admission to the facility on December 14, 2024. The resident was cognitively intact with a BIMS score of 15 (brief interview for mental status, a tool to assess the resident's attention, orientation, and ability to register and recall new information a score of 13-15 equates to being cognitively intact) and a diagnosed intellectual disability. Resident 2 was transferred to the hospital on December 29, 2024. Interview with the resident's representative on December 30, 2024, revealed that while a copy of the facility's bed-hold policy was provided at admission, no written notification or explanation of the bed-hold policy,…

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 ensure timely completion of prescribed laboratory services for one resident out of six sampled (Resident 1). This failure resulted in a delay in the monitoring and management of the resident's elevated potassium levels as ordered by the prescribing practitioner. Findings included: Clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include diabetes, heart failure and morbid obesity. The resident's potassium levels (K+ normal range: 3.5-5.1 mmol/L Potassium is a mineral found in the foods you eat. It ' s also an electrolyte. Electrolytes conduct electrical impulses throughout the body. They assist in a range of essential body functions, including blood pressure, normal water balance, muscle contractions, nerve impulses, digestion, and heart rhythm) were documented as follows: November 15, 2024: 5.4 mmol/L (elevated) November 19, 2024: 5.4 mmol/L (elevated) November 20, 2024:…

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

Based on observation, review of the facility's infection control tracking logs, facility policy, and staff interviews it was determined the facility failed to maintain a comprehensive program to monitor the development and spread of infections within the facility and plan preventative measures accordingly and failed to ensure the consistent implementation of infection control procedures designed to prevent the potential for the spread of infection during ice storage for one of two resident pantries (East Nursing), medication administration and multi resident use blood glucose monitors for one of 3 residents sampled (Resident 77). Findings include: A review of the facility's infection control data conducted during the survey ending August 30, 2024, revealed the facility's infection control tracking did not reflect evidence of a functional tracking system to monitor and investigate causes of infection and manner of spread. There was no documented evidence of a functional system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of facility provided documents, and resident and staff interview, it was determined the facility failed to maintain an effective pest control program, including observations made on two of the two nursing units (East and West) and experiences reported by two residents out of 24 sampled. (Residents 77 and 90). Findings include: A review of a pest management detailed report dated August 16, 2024, revealed the following summary of recommendations to effectively manage pest and rodent activity at the facility: Recommendations made on May 10, 2024, included all {damaged} exterior grates under windows along the exterior that need to be replaced, which can allow rodents access to the interior. Recommendations made on June 22, 2024, included repairing door gaps that allow pest entrance. Recommendations made on July 10, 2024, included the facility exterior grates needed repairs. Holes leading into air-conditioning units allow rodent travel, fill in gaps between pipes and walls to prevent…

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

Based on observations and staff interviews, it was determined the facility failed to maintain residents right to privacy and confidentiality during a physician visit for 7 residents and failed to ensure personal privacy for one resident (Resident 78) by placing health care instructions in a place compromising the resident's privacy. Findings include: During an observation August 27, 2024 at 10 AM, seven residents were seated in wheelchairs in the resident lounge (located in the hallway between the 2 nurses stations) and one resident seated a wheelchair in the hallway, outside of the lounge. The contracted eye doctor was examining an additional resident at a table in the room. There was no screen or partition separating the Physician and the resident being examined from being seen by the residents in the room waiting to be seen or the residents, staff and visitors in the hallway outside of the activity room. The doors to the room were open and the walls were glass, allowing the activities inside the room to be viewed from the hallway. There was no activity at the time of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview it was determined the facility failed to develop a comprehensive person-centered plan of care to meet the individualized needs of one resident out 24 sampled (Resident 72). Findings include: Review of Resident 72's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include the presence of an automatic implantable cardiac defibrillator (AICD- is a microcomputer that is implanted under the skin of the upper chest area. It monitors heart rate and delivers therapy in the form of small electrical pulses. An AICD is a permanent device inserted into the right ventricle and typically placed near the collarbone under the skin of the chest) and complete traumatic amputation at the knee level of the left lower leg. A review of Resident 72's current comprehensive plan of care, conducted during the survey ending August 30, 2024, revealed there was no documented evidence the facility identified and addressed the resident's care…

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 and clinical records, and staff interview, it was determined the facility failed to conduct a timely bladder assessment and develop and implement an individualized plan to meet the resident's toileting needs, including timely staff assistance with toileting and incontinence management and justification for the continued use of an indwelling catheter for two residents out of 24 sampled residents (Resident 91 and 32). Findings include: A review of the facility policy titled Urinary Continence and Incontinence - Assessment and Management last reviewed by the facility on July 1, 2024, revealed the staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence, manage incontinence following relevant clinical guidelines, provide appropriate services and treatment to help residents restore or improve bladder function, and prevent urinary tract infections to the extent possible. Residents will be assessed for information related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record and select facility policy review, and staff interview it was revealed the facility failed to monitor weight as planned to ensure acceptable parameters of nutritional status are maintained to the extent possible for two of 24 residents sampled (Residents 27 and 78) and failed to ensure a physician ordered fluid restriction was maintained for one of 24 sampled residents (Resident 25). Findings include: Review of facility policy entitled Weight Assessment and Intervention, last reviewed by the facility on July 1, 2024, indicated that resident weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team. Any weight change of 5-percent or more since the last weight assessment is obtained 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 weight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, and staff, resident and resident family interviews, it was determined the facility failed to ensure the physician provided services that met the resident's immediate care and needs for two out of 24 residents reviewed (Residents 77 and 260). Findings include: A review of policy titled Medication Orders: Prescriber Medication Orders, last reviewed by the facility on July 21, 2024, revealed that medication is administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. A review of policy titled Medication Ordering and Receiving from Pharmacy : Ordering and Receiving Controlled Medications, last reviewed by the facility on July 21, 2024, revealed that medications included in the Drug Enforcement Administration (DEA) classification as controlled substances and medications classified as controlled substances by state law, are subject to special ordering, receipt, and recordkeeping requirements in the facility,…

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 clinical records, and resident and staff interviews it was determined that the facility failed to provide sufficient nursing staff to consistently provide timely quality of care, services, and supervision necessary to maintain the physical and mental well-being of the residents for two of two nursing units including care, service, and supervision provided to Residents 41, 39, and 77. Finding include: During interview on August 27, 2024, at 11:00 AM Resident 41, a cognitively intact resident, noted that she wishes communication between regular and agency staff was better. Resident 41 stated that approximately three weeks ago on third shift she waited approximately two hours for her call bell to be answered and offered the bed pan. During an interview on August 27, 2024, at 11:15 AM, Resident 77, a cognitively intact resident, indicated he is worried his blood sugar is high because of the way he feels. He explained he was in the community hospital this morning and returned to the facility at 8:30 AM, but he hasn't received his morning insulin…

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 staff interviews it was determined that the facility failed to store drugs and pharmacy supplies in a safe manner in one medication storage room out of two medication storage rooms and failed to remove medications awaiting final disposition in a timely manner and failed to document the accounting and disposition of residents' medications in the clinical record upon discharge of two of two sampled residents (Residents 108 and 107) and failed to ensure accurate narcotic accountability for one of 6 residents sampled (Resident 84). Findings include: Observation of the East Wing medication storage room conducted on [DATE], at approximately 11:50 AM, in the presence of Employee 8 (Registered Nurse Supervisor), revealed a large paper bag on top of a filing cabinet, filled with 12 discontinued resident medication blister cards, 75 plastic medication sleeves, and 8 boxes of resident breathing treatments that were left unsecured. Interview with Employee 8 at the time of the observation, confirmed…

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 the facility failed to ensure a medication error rate of less than 5% for one of 4 residents (Residents 6 ) observed. Findings include: A review of the clinical record revealed that Resident 6 was admitted to the facility on [DATE], and had diagnoses that included psychosis, diabetes. A quarterly MDS assessment dated [DATE], indicated the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status a tool used to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) and the resident required limited staff assistance for activities of daily living. A review of current Physicians orders, initiated November 14, 2019 revealed Lactase Tablet(an enzyme ro complete digestion of whole milk), 3000 units by mouth before meals for lactose intolerance to be give at 8:00 AM prior to breakfast, as per residents request.…

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 the facility failed to assure that two residents out of 24 sampled were free of a significant medication error (Resident 5 and 77). Findings include: A review of the clinical record revealed that Resident 5 was admitted to the facility on [DATE], with diagnoses to include congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Resident 5 had a physician order dated August 12, 2024, for Coumadin or Warfarin Sodium tablet 3 MG (anticoagulant or blood thinner to prevent blood clots) to give one tablet by mouth in the evening every Mon, Wed, Fri, Sun for treating/preventing blood clots related to unspecified atrial fibrillation (abnormal heart rhythm). A review of the Medication Administration Record (MAR) for August 2024, revealed Resident 5's Warfarin was scheduled for 9:00…

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, facility provided documentation, clinical records and staff interview, it was determined the facility's Quality Assurance Performance Improvement (QAPI) committee failed demonstrate effective and thorough adverse event monitoring and response and use of the monitoring data to prevent similar adverse events in the facility in response to residents with repeated falls for 2 of 24 sampled residents (Resident 91 and 33) and implement any applicable performance improvement activities. Findings include: A review of a facility policy for Quality Assurance Performance Improvement reviewed July 2024 revealed, This 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. provide a means to establish 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 select facility policy and clinical records, and staff interview, it was determined the facility failed to offer and/or provide the pneumococcal immunization, unless the immunization was medically contraindicated or the resident has already been immunized, to 3 of five residents reviewed (Residents 31, 27 and 91). Findings include: A review of facility policy titled Pneumococcal Vaccine last reviewed July 1, 2024, revealed prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine. When indicated, the vaccine will be offered and be administered within 30 days of admission. Assessments of pneumococcal vaccination status are conducted within five working days of the resident's admission if not conducted prior to admission. A review of the clinical record revealed that Resident 31 was admitted to the facility on [DATE], with diagnoses to include cerebral infarction (stroke) and COPD (chronic obstructive pulmonary disease- a group of lung diseases…

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 a review of employee personnel records it was determined the facility failed to provide abuse prevention training to two employees out of two reviewed. (Employee 7 and 15 ). Findings include: During an interview with Employee 7 (agency LPN) on August 29, 2024 at 9:45 a.m she stated she had worked a couple of shifts at the facility since July 2024. Employee 7 stated she was never trained on the facility's abuse prohibition policy prior to assuming her duties today. There was no documentation that Employee 7(agency LPN) was trained on the facility's abuse prohibition policies and procedures as part of staff orientation and training on the prohibition of all forms of abuse, neglect, and exploitation prohibition. During an interview with Employee 15 (agency RN supervisor) on August 30, 2024 at 11 a.m she stated this was her first day working at the facility. Employee 15 stated she was never trained on the facility's abuse prohibition policy prior to assuming her duties today. There was no documentation that Employee 15 (agency RN Supervisor) was trained 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 observations, review of clinical records, and resident and staff interview, it was determined the facility failed to provide reasonable accommodation of the needs of a resident with sensitive skin for one of 24 residents reviewed (Resident 94). Findings include: A review of the clinical record revealed that Resident 94 was admitted to the facility on [DATE], with diagnoses to include Crohn's disease (chronic inflammatory bowel disease that affects the lining of the digestive tract which can result in diarrhea and bloody stool). During an interview with Resident 94, a cognitively intact resident, on August 29, 2024, at 9:10 AM, the resident stated she has a problem with diaper rash and that her skin is easily irritated due to her diagnosis of Crohn's disease. Resident 94 further stated she does have episodes of fecal incontinence and when staff are cleaning her with a washcloth after a bowel movement it feels like her skin is ripping. Resident 94 stated that disposable cloths are so much nicer, cleaner,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interviews, it was determined the facility failed to timely consult with the resident's physician regarding the need to initiate a new treatment for one resident out of 24 sampled (Resident 72). Findings include: A review of Resident 72's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include complete traumatic amputation at the knee level of the left lower leg, and abnormalities of gait and mobility. The resident had a physician order dated July 17, 2024, for nursing staff to cleanse his left BKA (below the knee amputation) with NSS (normal saline solution), pat dry, apply TAO (triple antibiotic ointment) to the open wound followed by application of a 4x4 (gauze pad), kerlix (gauze roll), and ace bandage every evening shift for wound care. A review of the resident's Report of Consultation form dated August 12, 2024, signed by the CRNP (certified registered nurse practitioner) from the Vascular Surgeon's office stated…

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, and staff interview it was determined the facility failed to ensure the resident received enteral feedings as prescribed for one resident receiving an enteral feeding out of two residents sampled (Resident 31). Findings include: Review of Resident 31's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include cerebral infarction (stroke) and dysphagia (difficulty swallowing). Resident 31 required a percutaneous endoscopic gastrostomy (PEG tube) also known as G-tube (gastrostomy tube is a medical procedure in which a tube is passed into the patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate for enteral feeding [enteral nutrition generally refers to any method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements). Current physician orders initially dated July 12, 2024, noted an order for Glucerna 1.5,…

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 ensure the physician wrote a progress note with each visit for one of 24 sampled residents (Resident 27). Findings include: According to regulatory guidance at 483.30 (b) the physician must write, sign, and date progress notes at each visit. A review of the clinical record revealed that Resident 27 was admitted to the facility on [DATE], with diagnoses which included dementia (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 diabetes. Resident 27's clinical record revealed on August 6, 2024, the attending physician was in the facility on this date to see this resident. However, there was no physician progress note in the resident's clinical record to correspond with the noted physician visit on August 6, 2024. Interview with the regional nurse consultant on August 30, 2024, at 10:00 AM failed to…

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

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 ensure that one resident of 24 sampled was seen timely by a physician for the initial comprehensive visit (Resident 91). Findings include: A review of the clinical record for Resident 91 revealed admission to the facility on July 24, 2024 with diagnosis to include 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 abnormalities of gait and mobility. A review of nursing notes from July 24, 2024 through August 13, 2024, revealed Resident 91 exhibited agitation and physical aggression toward staff, wandering and exit seeking behaviors, Foley catheter self-removal (Foley catheter is a plastic tube inserted into the bladder and draining into a collection bag), a medication error, and five falls with the last fall on August 13, 2024, resulting in a left hip fracture. On August 14, 2024, resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined the facility failed to ensure the resident's drug regimen was free of unnecessary antibiotic medication for one out of 24 residents sampled (Residents 77). Findings included: A clinical record review revealed Resident 77 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (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). A review of Resident 77's care plan revealed he uses an indwelling urinary catheter related to neuromuscular dysfunction of the bladder initiated on February 14, 2023. A community hospital emergency department document dated August 27, 2024, at 12:33 AM indicated Resident 77 was evaluated with no evidence of continued hematuria (blood in urine). Resident 77 was to be discharged back to the facility with a urology follow-up and prescribed Keflex 500 mg oral capsule for dysuria (pain…

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, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and use by dates for multi-dose medications in one of two medication storage rooms observed (West medication storage room). Findings include: Review of the facility policy titled Medication labeling and Storage last reviewed by the facility July 1, 2024, indicated that multi-use vials that have been opened or accessed (e.g. needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Observation of the medication room on the [NAME] Wing on August 29, 2024, at 11:05 AM, in the presence of Employee 7 (Licensed Practical Nurse) of medication stored in the medication refrigerator, revealed two (2) multi-dose vials of Aplisol (solution used for screening for tuberculosis) that had been opened and available for use, but not dated when initially opened. A review of the manufacturer dosage and administration for Aplisol revealed that vials in use 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 review of clinical records and staff interview, it was determined the facility failed to offer routine annual dental services for one resident with a Medicaid payor source out of 24 residents sampled (Resident 80). Findings include: Review of Resident 23's clinical record revealed admission to the facility on December 8, 2022, and the resident's current payor source was Medicaid. There was no documented evidence at the time of the survey ending August 30, 2024, the resident had been offered dental services in the past year. Interview with the Nursing Home Administrator on August 29, 2024, at 12:35 PM confirmed the facility had not offered Resident 80 routine dental services in the past year. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, information submitted by the facility and the facility's abuse prohibition policy and staff interviews, it was revealed the facility failed to timely report multiple instances of verbal and mental abuse perpetrated by one resident out of 10 sampled (Resident A1) to the State Survey Agency and local Area Agency on Aging. Findings include: A review of the facility's abuse prohibition policy, dated as reviewed by the facility May 1, 2024 revealed revealed that residents residents have the right to be free from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance to describe residents, regardless of their age, ability to comprehend or disability. According to long term care regulatory requirements under §483.12 Freedom from Abuse, Neglect, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and resident and staff interview, it was determined that the facility failed to provide person centered care by failing to follow physician's orders for the consistent application of a prescribed therapeutic measure, Ace wraps (elastic bandage), and further failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for diabetes management for one resident (Resident B1) of out of 10 sampled. Findings include: Review of the clinical record revealed that Resident B1 was admitted to the facility on [DATE], with diagnoses which included diabetes and chronic peripheral venous insufficiency (leg veins do not allow blood to flow back up to the heart). A review of Resident B1's clinical record revealed a physician's order dated June 10, 2024, to apply Ace wraps in the AM and remove at HS (at bedtime); may remove for care and hygiene; and to place back on until HS and remove every evening and night for edema. Interview…

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 resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life and assures that each resident is treated with dignity by failing to respond timely to residents' requests for assistance, as evidenced by experiences reported by two of four residents sampled (Residents B1 and B3). Findings include: During interview with Resident B1, a cognitively intact resident, on July 21, 2024, at 9:00 AM the resident stated that he often waits an extended period, greater than 15 minutes and at times more than one hour, for staff to answer the call bell. Resident B1 stated that when he rings the call bell it is often for toileting assistance or assistance to be placed back in bed after sitting on the side of the bed for exercise. During interview on July 21, 2024, at approximately 1:00 PM Resident B3, a cognitively intact resident, stated that in the morning before lunch she often waits an hour for staff to answer her call bell. Resident B3 stated that she will ring the call bell to request…

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 baseline care plan of one of 10. residents sampled (Resident B2) failed to fully address the resident's individual needs upon admission. Findings: A review of Resident B2's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included acute ischemic heart disease (disease or damage in the heart's major blood vessels). An admission physician order dated July 5, 2024, was noted for the resident to wear a life vest (a wearable defibrillator that can stop an abnormal heart rhythm without anyone's help) for sudden cardiac arrest. A review of the resident's baseline care plan failed to identify that the resident had a life vest and specific interventions to address the care of the resident while utilizing the life vest. An interview with the director of nursing on July 21, 2024, at approximately 11:00 AM confirmed the facility to ensure that this resident's baseline care plan included 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 observation, review of clinical records, and staff and resident interview, it was determined the facility failed to consistently provide timely and necessary foot care for one of 10 residents sampled (Residents B1). Findings include: Review of Resident B1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included diabetes and chronic peripheral venous insufficiency (leg veins do not allow blood to flow back up to the heart). Observation on July 21, 2024, at 9:00 AM revealed that Resident B1's toenails, on both feet, were thickened, yellowed, and extended past the tips of his toes. Resident B1 stated during interview at that time, that he had diabetes and was concerned that he was not routinely being seen by a podiatrist for foot care. Further review of the clinical record revealed that Resident B1's last podiatry visit was on January 8, 2024. Interview with the Director of Nursing on July 21, 2024, at approximately 1:00 PM, confirmed that Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview it was determined that the facility failed to timely obtain and provide necessary respiratory care supplies and equipment required by one one of 10 sampled residents (Resident A3). Findings include: Clinical record review revealed that Resident A3 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia, dyspnea, sleep apnea and anxiety. The resident had a tracheostomy surgically placed during her recent hospital stay prior to admission to the facility. A review of a 5-day admission Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 21, 2024, revealed that Resident A3 was cognitively intact and required staff assistance for activities of daily living. The resident had a physician order, dated June 21, 2024, to change disposable inner cannula, (4DIC) two times a day. When reviewed during the survey ending July 21,…

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 pharmacy services to assure timely acquiring of physician ordered medications for one of 10 residents sampled. (Resident A3). Findings include: A review of the clinical record revealed that Resident A3 was admitted to the facility on [DATE], with diagnosis to include narcolepsy (Narcolepsy is a chronic neurological disorder that impairs the ability to regulate sleep-wake cycles, and specifically impacts REM sleep). A physician order dated July 10, 2024, was noted for Modafinil 200 mg, one tablet via the PEG tube (a plastic tube inserted into the stomach for liquid nutrition when a person can not eat by mouth) one time a day for anti-narcolepsy. A review of the resident's July 2024 medication administration record (MAR) revealed that the resident did not receive the prescribed medication from July 10, 2024, 2024, through July 20, 2024. The MAR indicated that the resident received the first dose of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interviews it was determined that the facility failed to ensure the consistent implementation of infection control procedures designed to prevent the spread of infection in the facility. Findings include: An observation April 23, 2024 at 12 PM revealed Employee 1 (RN ) dropped multiple pills and medication capsules from a plastic bag container onto the top of the medication cart, Employee 1 was then observed to pick the medications up with her bare hands and then place them into the plastic container (utilized to crush the pills). The crushed medications were then placed into a medication cup, applesauce added, and administered to the resident. An interview at the time of the observation, Employee 1 (RN) stated that she had just washed her hands prior to handling the medications, which had not been observed by the surveyor. An observation on April 23, 2024 at 2 PM in the bathroom of resident room [ROOM NUMBER] revealed an uncovered speci-hat ( a urine/feces…

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 timely obtain prescribed laboratory services for one resident out of 10 sampled (Resident CR1). Findings included: Clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disease and a history of pulmonary embolus (a blood clot in the lungs). A review of nursing documentation dated April 8, 2024, at 11:42 AM revealed that the physician assistant saw the resident and ordered Robitussin (cough medicine) 10 ml at bedtime for 7 days. A nurses note dated April 10, 2024 at 11:37 AM revealed that the physician's assistant noted an order to obtain a full respiratory panel swab due to the resident's chronic cough not relieved with cough syrup. A nurses note dated April 11, 2024 at 3:28 P.M revealed that the respiratory panel swab was collected and sent to the lab. When the resident's record was reviewed at the time of the survey ending April…

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 controlled drug records and staff interview, it was determined that the facility failed to implement pharmacy procedures to promote accurate accounting and administration of controlled medications for two of 10 residents sampled (Resident 40 and Resident 76). Findings include: A review of the clinical record revealed Resident 40 was admitted to the facility on [DATE], with diagnoses to include alcoholic cirrhosis of the liver, end stage renal disease and acute respiratory failure with hypoxia. The resident had physician orders dated March 20, 2024, for Oxycodone 5 mg tablet, give 1 tablet by mouth every 6 hours as needed, which may be taken with Benadryl 25 mg by mouth (po) every 6 hours as needed, and discontinued on March 21, 2024. The resident also had physician orders dated March 21, 2024, for Oxycodone 5 mg tablet, give 5 mg by mouth every 4 hours as needed, may take with Benadryl 25 mg by mouth (po) every 6 hours as needed. Hold for sedation. The physician order…

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 ensure that medications were labeled according to accepted labeling requirements for two of 10 residents sampled (Resident 40, and 76). Findings include: Labeling for prescription medicines is FDA ' s primary tool for communicating drug information to healthcare professionals, and patients and their caregivers. Labeling for prescription medicines includes: Prescribing Information (labeling for healthcare professionals); Carton and container labeling (cartons and containers are outside packaging that contain information about prescription medicines), and; Labeling for patients or caregivers (e.g., Medication Guides, Patient Package Inserts, and Instructions for Use). A review of the clinical record revealed Resident 40 was admitted to the facility on [DATE], with diagnoses to include alcoholic cirrhosis of the liver, end stage renal disease and acute respiratory failure with hypoxia. The resident had 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 a review clinical records, the facility's plan of correction from the surveys ending February 29, 2024, and February 1, 2024, and the outcome of the activities of the facility's quality assurance committee it was determined that the facility failed to develop and implement a quality assurance plan, which was able to identify and correct ongoing quality deficiencies related to fully developing and implementing operational policies and procedures designed to protect residents from unacceptable practices of facility initiated disenrollment of residents from their Medicare health plans, the implementation of pharmacy procedures to promote accurate controlled drug records and administration, the pharmacist's identification of irregularities in residents' drug regimens and respiratory care. Findings include: During the survey ending February 29, 2024, deficient facility practice was identified related to the facility's failure to develop policies and procedures in accordance with CMS (Center for Medicare and Medicaid Services) guidance to protect the resident from unacceptable…

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 guidance issued by the Centers for Medicare and Medicaid Services, select facility policy, and staff interview, it was determined that the facility failed to fully develop and implement operational policies and procedures designed to protect residents from unacceptable practices of disenrolling residents from their Medicare health plans. Finding include: During an abbreviated complaint survey conducted at the facility on February 29, 2024, deficient facililty practice was cited related to the facility's practice of initiating changes in residents' Medicare insurance plans, without the resident or their representatives having requested these changes, assessment of the resident's cognitive capabilities for understanding the changes and in the absences of operational policies and procedures consistent with CMS guidance for disenrollment. The facility's plan of correction for this deficient practice, to be completed by March 19, 2024, revealed that the facility had developed a policy to allow residents or their representatives to request assistance from the facility…

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 interviews with staff, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to demonstrate prompt and thorough assessment of a resident displaying signs and symptoms of a change in condition to ensure the resident received timely and necessary treatment for one resident out of 10 sampled (Resident CR1), which resulted in the facility's failure to timely identify signs of digoxin toxicity. Findings include: 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 collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational…

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 consistently provide respiratory care in manner to promote safe and optimal functioning for two residents out of 10 sampled (Residents 7, and 29). Findings included: A review of Resident 7's clinical record revealed admission to the facility March 25, 2023, with diagnoses to include chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia and asthma. A current physician order dated February 14, 2024, was noted for Ipratropium - Albuterol Solution 0.5 - 2.5 (3) mg/3 ml, take 3 ml inhale orally every 6 hours as needed for shortness of breath (SOB) or cough via nebulizer. An observation conducted on March 21, 2024, at approximately 12:05 PM, revealed Resident 7 in his room. A nebulizer machine and tubing and mask was observed on a metal folding chair. The tubing and mask were in a clear plastic bag, dated February 29, 2024, which was confirmed by Employee 1 (LPN) at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and resident and staff interview, it was determined that the facility failed to provide person-centered pain management consistent with professional standards of practice for one resident out of ten sampled (Resident 76). The findings include: According to the US Department of Health and Human Services, Interagency Task Force, Executive Summary Final Report May 6, 2021, for Pain Management Best Practices the development of an effective pain treatment plan after proper evaluation to establish a diagnosis with measurable outcomes that focus on improvements including quality of life (QOL), improved functionality, and Activities of Daily Living (ADLs). Achieving excellence in acute and chronic pain care depends on the following: -An emphasis on an individualized patient-centered approach for diagnosis and treatment of pain is essential to establishing a therapeutic alliance between patient and clinician. -Acute pain can be caused by a variety of different conditions such as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the pharmacist failed to identify drug irregularities in the drug regimen of one of 10 sampled residents (Resident CR1). Findings included: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses of chronic atrial fibrillation (a disease of the heart characterized by irregular and often faster heartbeat), chronic obstructive pulmonary disease ([COPD] a disease characterized by persistent respiratory symptoms like progressive breathlessness and cough), and a history of peptic ulcer disease ([PUD] an illness characterized by open sores called ulcers in the stomach). Hospital discharge instructions dated dated January 23, 2024, at 9:56 AM, revealed that future medications the resident was to be prescribed at the skilled nursing facility included digoxin (Lanoxin - used to treat a-fib) 125 micrograms (mcg) at bedtime, which staff were to hold for a heart rate of less than 60 beats…

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, facility provided documents, and staff interviews, it was determined that the facility failed to maintain complete clinical records, according to professional standards of nursing practice by failing to document assessment of changes in a residents condition for one of 10 residents sampled (Resident CR1). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated…

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, and medication records, and resident and staff interviews it was determined that the facility failed to provide pharmacy services, routine drugs and pharmaceuticals, to ensure timely medication administration as prescribed for one resident out of 14 sampled (Resident CR1) and failed to implement pharmacy procedures for accounting for controlled drugs on one of four medication carts. Findings included: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses, of end stage kidney disease, pain, and end of life care with hospice services. The resident arrived at the facility at approximately 1 PM and was accompanied by family and hospice nurse. A review of the resident's February 2024 Medication Administration Record (MAR) revealed that the resident was prescribed Lorazepam oral concentrate 2 mg/mL give 0.25 ml by mouth every 6 hours for anxiety/terminal agitation and was scheduled for 12 AM, 6…

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 policies, clinical records and select resident incident/accident reports and staff interview, it was determined that the facility failed to consistently implement planned, and functional safety interventions based on individual resident needs to promote resident safety and prevent repeated falls for one of 18 sampled residents (Resident 4) Findings include: A review of the clinical record revealed that Resident 4 was admitted to the facility on [DATE], with diagnoses to include intermittent explosive disorder and intellectual disability. A 5-Day/admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated February 17, 2023, indicated that Resident 4 was severely cognitively impaired with a BIMS (brief screener that aids in detecting cognitive impairment) score of 0. Nursing progress notes in the resident's clinical record dated between February 14, 2024 through February 23, 2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, CMS guidance and facility documentation, and staff and resident interviews, it was determined the facility failed to develop policies and procedures in accordance with CMS (Center for Medicare and Medicaid Services) guidance to protect the resident from unacceptable practices of disenrolling residents from the Medicare Health Plans to ensure all risks of disenrolling are fully explained, both verbally and in writing, and that residents are assessed as competent at the time to make informed health care decisions for one resident of five reviewed (Resident 11). Finding include: A review of a CMS guidance titled 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,…

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 provide the necessary behavioral health care and services to meet the behavioral health needs and promote the highest level of physical, mental and psychosocial well-being of one of 18 sampled residents (Resident 4). Findings include: Review of clinical record of Resident 4 revealed that the resident was admitted to the facility on [DATE], with diagnoses including intellectual disabilities, intermittent explosive disorder, anxiety, and schizophrenia. Prior to admission to the nursing home, the resident had been living in a group home for approximately forty years. A 5-Day/admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated February 17, 2023, indicated that Resident 4 was severely cognitively impaired with had a BIMS (brief screener that aids in detecting cognitive impairment) score of 0. Further review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the pharmacist failed to identify drug irregularities in the drug regimen of one of 18 sampled residents (Resident 7). Findings included: A review of Resident 7's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included Parkinson's disease (a progressive, neurological disorder) and Type 2 Diabetes. A physician order dated October 5, 2023, at 3:50 PM, was noted for Acetaminophen 500 milligrams (mg) ([Tylenol] a non-steroidal pain and fever reducer) by mouth every four hours as needed for pain. A physician order dated October 5, 2023, at 3:50 PM was noted for Acetaminophen 650 mg suppository rectally every four hours as needed for temperature greater than 100.4 degrees, do not exceed 3000 mg in a 24-hour period. A physician order dated October 5, 2023, at 3:50 PM was noted for Acetaminophen 325 mg give two tablets by mouth totaling 650 mg every four hours as needed for temperature greater…

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, clinical records and staff interviews it was determined that the facility failed to ensure that one resident's drug regimen was free of unnecessary antibiotic drugs for one out of 18 residents sampled (Resident 11). Findings included: Review of a facility policy entitled Antibiotic Stewardship indicated that the purpose of the antibiotic stewardship program was to monitor the use of antibiotics in their residents. When a nurse calls a physician/prescriber to communicate a suspected infection, they will have information available to include, signs and symptoms, when they were first observed, hydration status, medication list, allergies, infection type, laboratory results and the time of the last antibiotic dose. A review of the clinical record revealed that Resident 11 was admitted into the facility on January 12, 2024, with diagnoses including methicillin resistant staphylococcus aureus (MRSA) infection (infection caused by bacteria that are resistant to commonly used antibiotics that can cause headache, pain, fever, shortness of breath…

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 the minutes from Residents' Council meetings and grievances lodged with the facility and staff and resident interviews it was determined that the facility failed to demonstrate efforts to respond and resolve resident complaints raised at resident group meetings including those voiced by Residents 2, 3, 4, 5, and 6. Findings include: A review of the minutes from the Resident Council meeting dated December 28, 2023, revealed no reference to any concerns raised by the residents during the meeting regarding staff's response to their requests for assistance via the nurse call bell system. A review a concern/grievance form lodged with the facility, however, dated December 28, 2023, filed on behalf of residents in attendance at the December 28, 2023, Resident Council meetings, revealed that Residents 2, 3, 4, 5 and 6 stated that staff on the 3 PM to 11 PM shift are turning off their call bells, telling the residents that they will come back to meet their needs, but then do not return to provided the needed care to the residents. The residents stated that this is 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 a review of clinical records and staff interview it was determined that the facility failed to ensure that residents dependent on staff for assistance with activities of daily living consistently received showers as planned to maintain good personal hygiene for two of 11 residents sampled (Resident 9 and 10). Findings include: A review of Resident 9's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included dementia cerebral palsy ( a progressive neurological disease). A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 9 dated November 6, 2023, indicated that the resident was totally dependent on staff for bathing/showers. The resident was cognitively intact with a BIMS score of 15 (brief interview for mental status, a tool to assess the residents' attention, orientation, and ability to register and recall new information, a score of 15…

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 nursing staffing hours and ratios, resident census, clinical records, and grievances lodged with the facility observations, resident and staff interviews it was determined that the facility failed to provide sufficient nursing staff to consistently provide timely quality of care, services, and supervision necessary to maintain the physical and mental well-being of the residents. Findings include: A review a concern/grievance form lodged with the facility, however, dated December 28, 2023, filed on behalf of residents in attendance at the December 28, 2023, Resident Council meetings, revealed that Residents 2, 3, 4, 5 and 6 stated that staff on the 3 PM to 11 PM shift are turning off their call bells, telling the residents that they will come back to meet their needs, but then do not return to provided the needed care to the residents. The residents stated that this is a frequent occurrence. The facility's noted plan to resolve the concern/grievance was to hold a meeting for all nurse aides…

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

Based on observations and staff interviews, it was determined the facility failed to maintain sanitary conditions in the facility's central supply area. Findings included: An observation February 1, 2024 at approximately 10 AM in the facility's central supply area revealed that the the floors were soiled with dried liquid stains and littered with paper and plastic debris. Clean resident care products and equipment were observed directly on the floor. There were multiple dirty uncovered oxygen concentrators, multiple dirty uncovered tube feeding poles with the tube feeding pumps attached. Observation of the tube fed pumps revealed dried tube feeding solution adhered to the pumps. There were several boxes of disposable gloves on the floor. There were several opened boxes of unwrapped dressing supplies on the shelves. Multiple boxes of resident care supplies were observed directly on the floor. Therapy supplies, both dirty and clean, were located stored together on the shelves and observed directly on the floor. There was an uncovered resident commode chair on which several opened…

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, review of clinical records, and staff and resident interview, it was determined the facility failed to consistently provide timely and necessary foot care for two of 11 residents sampled (Residents 4 and 9 ). Findings include: Review of Resident 4's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included hemiplegia (inability to use one side of the body(. Observation on February 1, 2024 at 12:30 PM revealed that Resident 4's toenails, on both feet, were thickened, yellowed, and extended past the tips of his toes. Resident 4 stated during interview at that time, that he was not seen by a podiatrist at the facility. Further review of the clinical record revealed that this resident had not been seen by podiatry during his stay in the facility. Review of Resident 9's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included cerebral palsy ( a progressive, neurological disease).…

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 consistently provide respiratory care, supplemental oxygen, as ordered by the physician for one resident out of 11 sampled (Resident 1). Findings included: A review of Resident 1's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses to include chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease (a chronic respiratory illness). A quarterly MDS (minimum data set- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 21, 2024, indicated that the resident required staff assistance with activities of daily living. The resident was severely cognitively impaired with a BIMS score of 6 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 0-7 equates to being severly cognitively impaired). 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, and staff interview, it was determined that the facility failed to implement procedures to promote accurate controlled medication records for two residents (Residents 11, and 140) and for acquiring resident medications to ensure physician-ordered medications were available in a timely manner for one resident out of 19 residents reviewed (Resident 13). Finding include: A review of the clinical record revealed that Resident 11 was admitted to the facility on [DATE], with diagnoses of Fibromyalgia (a medical condition defined by the presence of chronic widespread pain, and fatigue) and chronic pain. The resident had physicians orders dated June 26, 2023 to July 17, 2023 for Ultram (Tramadol- an opioid pain medication) 50 milligrams (mg) by mouth every 8 hours as needed for moderate pain; an physician order was noted August 24, 2023 for Tramadol 50 mg by mouth every 6 hours as needed for moderate pain, and orders dated September 13, 2023 until September 22, 2023 for Norco…

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.