Ivory Wellness Center

Based on review of clinical records and interview with staff, it was determined that facility did not ensure to provide pertinent information regarding the immunizations to the resident or the resident's representative such as the benefits and potential side effects of the influenza and, as applicable, the pneumococcal immunization for 18 out of 100 residents reviewed ( Resident R66, R105, R32, R15, R118, R54, R102, R55, R51, R100, R93, R109, R62, R83, R69, R94, R99, R76)Findings include:Review of facility policy 'Pneumococcal Vaccine,' revised March 2023, indicates that before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education is documented in the resident's medical record.Review of facility policy 'Influenza Vaccine.' Revised August 29, 2025, indicates that prior to vaccination , the resident (or resident's legal representative) or employee will be provided information and education regarding the benefits and potential…

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 interview with staff, it was determined that facility did not ensure to provide pertinent information regarding the immunizations to the resident or the resident's representative such as the benefits and potential side effects of the covid-19 immunizations for two out of 100 residents reviewed (Resident R116 and R29)Findings include:Review of Resident R116's clinical record indicates covid-19 immunization was administered on November 8, 2024; there was no documented evidence that education was provided.Review of Resident R29's clinical record indicates covid-19 immunization was administered on December 3, 2024; there was no documented evidence that education was provided.Interview with facility's director of nursing, employee E1, on Wednesday, September 24, 2025, at 11:20 am, confirmed that education was not provided prior to administering vaccinations.28 Pa Code 201.14(a) Responsibility of licensee28 Pa Code 201.18(b)(1) Management28 Pa Code 211.15(f) Clinical records

Based on observation and employee interviews, it was determined that the facility failed to maintain the dish washing machine in the main kitchen and the med storage refrigerator on the second-floor medication room in an operating condition.Findings include: Observation on September 23, 2025, at 1:30 p.m. during a follow-up tour of the dietary department with the Food Service Director (FSD), Employee E3, revealed that the dish washing machine had a final rinse temperature of 120 degrees. When asked about this the FSD indicated that the booster heater had recently been worked on but was still waiting for parts and they were to be using it as a low temperature chemical sanitizing machine. When asked to check the chlorine ppm, the FSD got no reading on his test strips. It was noted that the plastic tubing was laying on the floor next to a closed gallon jug of household bleach. The FSD removed the cap and put the tubing into the jug of bleach and ran the machine for several minutes. After allowing the machine to run for a few minutes with empty dish racks going through he tested the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations in the food and nutrition department, and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. Findings Include: Review of facility policy Food Storage dated August 2024, revealed food items will be stored, thawed, and prepared in accordance with good sanitary practice. All products shall be dated upon receipt or when they are prepared. Further review of facility policy revealed meat should be dated when taken out of the freezer. Dented cans should be placed on damaged good shelf and returned for credit. Any opened products shall be placed in containers with tight-fitting lids or Ziploc bags. All foods shall be stored off the floor. A tour of the main kitchen was conducted with the Food Service Director, Employee E21, on October 28, 2024, at 8:45 a.m. revealed the following: Interview with the Food Service Director, Employee E21,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and staff and resident interviews it was determined that the facility failed to maintain a clean, comfortable, and home-like environment for one of two nursing units observed (room [ROOM NUMBER]-B). Findings Include: Observations on October 29, 2024, at 10:28 a.m., revealed in the closet for Resident R15, room [ROOM NUMBER]-B, clothes were thrown in a messy pile in the closet. Observations revealed the rod in the closet had fallen, so staff were unable to hang the resident's clothes as intended. Interview on October 29, 2024, at 10:30 a.m. with alert and oriented Resident's R17 and R69 revealed the closet rod had been broken for a while. Observations on October 29, 2024, at 10:35 a.m. with the Director of Nursing, Employee E2, confirmed the closet rod in room [ROOM NUMBER]-B was broken and the resident's clothes were thrown in a pile. 201.14 (a) Responsibility of licensee.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of facility documentation, review of clinical records, and staff interview, it was determined that the facility failed to ensure medication regimen reviews were completed monthly by a licensed pharmacist and failed to ensure recommendations were reviewed timely by the physician for 4 of 5 residents reviewed (Resident R88, R28, R6, and R40). Findings Include: Review of facility policy, Medication Regimen Review dated September 2023, revealed The Medication Regimen Review is a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing consequences associated with medication. The review includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities, and collaborating with other members of the interdisciplinary team. Continued review revealed, The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.…

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, review of facility documentation, and staff and resident interviews, it was determined that the facility failed to ensure menus were followed and provided variety for two of two nursing units observed (1st and 2nd floor nursing units). Findings Include: Review of the facility Spring/Summer Menu 2024 Week 1 (menu for the week of survey) revealed on Monday October 28, 2024, apple cinnamon oatmeal and French toast was on the menu for breakfast. Observations in the main kitchen on October 28, 2024, at 8:45 a.m. revealed dietary staff preparing breakfast meal trays for the residents via a tray line system. Further observations revealed no apple cinnamon oatmeal was available. Interview on October 28, 2024, at 8:45 a.m. with the Food Service Director, Employee E21, confirmed Apple Cinnamon Oatmeal was on the menu for breakfast but was unavailable. Further interview with the Food Service Director, Employee E21, revealed cream of wheat was being served instead. Continued observations on October 28, 2024, during breakfast tray line revealed toward the end of tray line…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with residents and staff, it was determined that the facility failed to ensure that food was palatable and served at appetizing tempertaures. Findings include: A test tray was completed on October 28, 2024, at 9:15 a.m. with Food Service Director, Employee E21, on the second-floor nursing unit, during the breakfast meal service. The outcome of the test tray revealed the following: waffles were 108.7 degrees Fahrenheit (F), bacon was 86.7 degrees F, and the hard-boiled egg was 97.3 degrees F. A taste test of the food items revealed the food was cold and unappetizing to taste. The waffles were tough and chewy, making them difficult to eat. Interview on October 28, 2024, at 9:27 a.m. Resident R18 stated that the food does not taste good and that he often buys his own food because he is unable to eat the facility's food. Interview on October 28, 2024, at 9:50 a.m. Resident R23 stated that the food is often served cold and does not taste good. Interview on October 28, 2024, 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.

Based on review of facility documentation and interviews with staff, it was determined that the facility failed to maintain an effective, comprehensive, data-driven quality assurance and performance improvement program (QAPI) that focuses on indicators of the outcomes of care and quality of life as required. Findings include: Review facility policy on Quality Assurance and Performance Improvement, Feedback, Data and Monitoring reveal that under section Policy: The QAPI program is based on the collection. Information obtained from data, self-assessment, and systems of feedback. Information is collected, evaluated, and monitored by the QAPI Committee. Under section Policy Interpretation and Implementation: #1 Information obtained about the quality of care and services delivered to residents is evaluated and monitored by the QAPI Committee In order to identify problems that are high risk, high volume, or problem prone and to guide decisions regarding opportunities for improvement. #2. The QAPI process focuses on identifying systems and processes that may be problematic and could be…

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 or observation, interview with staff and review of facility policy and documents, it was determine that the facility failed to develop and implement a Water Management Program for the prevention, detection, and control of water borne contaminants, such as legionella (a bacteria that causes Legionnaire's Disease). Findings include: Review of facility policy entitled Legionella Water Management Program with a most recent revision date of September 2022, revealed that under section Policy: Our facility is committed to the prevention, detection of water borne contaminants, including Legionella. Further review of the facility's Policy on Legionella Water Management Program revealed that the policy did not include an assessment which includes a description of the building water systems using text and flow diagrams to identify where Legionella and other opportunistic waterborne pathogens could grow and spread. Review of facility documents revealed that the facility did not have a documented water management program based on nationally accepted standards. Further review of 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 clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that a resident's transfer to the hospital was necessary and document the basis for the transfer in the resident's medical record for one of four residents reviewed related to transfers (Resident R55). Findings include: Review of Resident R55's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated September 9, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) and encephalopathy (brain damage). Continued review revealed that the resident was moderately cognitively impaired. Review of Resident R55's care plan, dated initiated September 8, 2024, revealed that the resident had behavioral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with staff, it was determined that the facility failed provide appropriate bed hold notice to a resident's representative of a facility-initiated transfer to the hospital for one of four residents reviewed related to transfers (Resident R55). Findings include: Review of Resident R55's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated September 9, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) and encephalopathy (brain damage). Continued review revealed that the resident was moderately cognitively impaired. Review of Resident R55's progress notes revealed a psychiatry (mental health) note, dated September 20, 2024, which indicated that the resident…

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

Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to develop a person-centered comprehensive care plan related to behaviors for one of 23 residents reviewed (Resident R63). Findings Include: Review of facility policy Care Plan - Interdisciplinary Plan of Care from Interim to Meeting dated February 2024 revealed the care plan describes or includes adequate information provided to make informed choices regarding treatment. Review of Resident R63's clinical record revealed a physician order dated March 17, 2024, for 1:1 supervision every shift. Interview on October 29, 2024, at 3:35 p.m. with the Director of Nursing, Employee E2, revealed Resident R63 required indefinite 1:1 supervision due to history of sexually inappropriate behaviors. Review of Resident R63's clinical record and review of past survey history confirmed Resident R63 had a behavior of being sexually inappropriate with other female residents. Review of Resident R63's comprehensive care plan dated August 8, 2019, revealed the resident was…

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

Based on review of facility policy, facility documentation, review of clinical records, observation, Pennsylvania code title 49 professional and vocational standards and staff and resident interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice related to safe and timely medication administration for two of eight residents observed. (Residents R99, and R57) Findings include: Review of facility policy titled Medication Dispensing System dated April 1, 2018, revealed all medication will be prepared and administer in a manner consistent with the general requirements outlined in the policy medications are to be administered in a timely fashion. Review of Policy titled Medication Administration Policy Times revealed that unless specified by the physician, medications will be administered within sixty minutes before or after the facility dosing schedule, except before or after meals orders and non-routine time ordered medications. The medications administration pass may begin sixty minutes…

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, review of facility documentation, and staff and resident interviews, it was determined that the facility failed to provide adequate staff supervision and failed to maintain a resident environment free of potential accident hazards relating to a resident gaining access to an exit door. (Resident R 306) Findings include: Review of facility policy titled Incident and Accident Policy and Procedure updated October 2024, revealed that the purpose of the policy is to outline the procedure for managing, reporting, and investigation incidents and accidents involving residents in long term care facilities. Continued review of the policy stated that an Incident is defined as unexpected or unplanned event that does not result in injury or harm but has the potential to do so. The policy is implemented to ensure prompt and appropriate responses to incidents and accidents involving residents, minimize the risk of harm to residents through preventative measures and establish a clear process for reporting, investigating and documenting incidents. Further review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, review of facility policy and interview with staff, it was determined that the facility failed to administer oxygen as ordered by the physician for one of one resident receiving oxygen therapy. (Resident R61) Findings include: Review of facility Policy on Oxygen Administration with a revised date of April 1, 2015, revealed that under section Policy it is the policy of this facility to provide comfort to residents by administering oxygen when insufficient oxygen is being carried by the blood to the tissue. Under section Procedure. #1 check physicians order for litter flow and method of administration. #7 All oxygen tubing is changed weekly and dated. Review of Resident R61's clinical record reviewed that Resident R61 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease (disease process that causes decreased ability of the lungs to perform), Acute Pulmonary Edema, Hypertension (high blood pressure), Morbid Obesity. Review…

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

Based on review of facility documentation, personnel records and interviews with staff, it was determined that the facility failed to complete annual performance reviews for nurse aide staff as required for three of five nurse aide personnel files reviewed (Employees E14, E16 and E18). Findings include: Review of facility documentation provided at the time of the survey pertaining to employee names, titles and dates of hire, revealed that Employee E14 was hired by the facility on June 22, 2003, as a nurse aide; Employee E16 was hired by the facility on January 17, 2017, as a nurse aide; and Employee E18 was hired by the facility on January 12, 1998, as a nurse aide. Review of Employees E14, E16 and E18's personnel files revealed that annual performance reviews were not available for review at the time of the survey. Interview on October 29, 2024, at 3:10 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that they were unsure if the facility had conducted any performance reviews for Employees E14, E16 and E18. Follow-up interview on October 30, 2024, 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 clinical record reviews and interviews with staff, it was determined that the facility failed to ensure proper monitoring and documentation of behaviors for two of 23 residents reviewed (Residents R40, and R6 ). Findings include: Review of Resident R40's Annual MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 15, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including schizophrenia (mental illness associated with loss of reality contact, delusions and hallucinations). Review of Resident R40's care plan, dated September 19, 2022, revealed that the resident had behaviors including aggression towards staff, use of profanity towards staff, refused consults, refused to wear proper footwear, refused to use assistive devices and that the resident responds to internal stimuli and may act on auditory hallucinations. Interventions included for staff to monitor and document the resident's behaviors, remind the resident to use his…

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

Based on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to serve foods that accommodate residents' allergies, intolerances and preferences for one of 23 reviewed (Residents R11). Findings include: Review of progress notes for Resident R11 revealed a nutrition note, dated September 17, 2024, at 2:33 p.m. which stated, Food preferences obtained, resident does not eat pork. Observation of the menu posted on the second floor nursing unit on October 28, 2024, revealed that the lunch meal was roast pork with gravy, roasted zucchini, mashed potatoes and yellow cake with topping. The alternate meal was baked chicken with brown gravy. Interview on October 28, 2024, at 12:39 p.m. Resident R11 stated that he was not able to eat his lunch. Observation, at the time of the interview, revealed that the resident was served pork. Continued observations revealed that the resident did not eat his meal and was not offered the alternate lunch item. Interview on October 30, 2024, at 8:45 a.m. with nurse aide, Employee E23,…

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

Based on observations, and staff interview, it was determined that the facility failed to maintain the kitchen in a sanitary environment to be free of pests. Findings Include: A tour of the main kitchen was conducted with the Food Service Director, Employee E21, on October 28, 2024, at 8:45 a.m. Observations in dry storage revealed a box of bananas stored on top of a plastic milk crate. Further observations revealed the bananas were extremely overripe and deteriorating (to the point that the bananas were beginning to liquify as evidenced by drippings beneath the box). The food service director picked up the box of bananas to remove from the dry storage room and a swarm of fruit flies scattered throughout the dry storage room. Interview with the Food Service Director, Employee E21, confirmed the bananas were the source of the fruit flies and should have been discarded. Observations above the prep sink revealed a long shelf along the wall storing condiments. Observations revealed a container of teriyaki sauce with drippings on the outside of the container making it sticky to touch.…

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 standards of professional practice, review of facility policy, observations in the food and nutrition department, and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. Findings Include: Review of the 2022 Food Code (a uniform system of provisions that address the safety and protection of food offered at retail and in food service), January 18, 2023 Version by the United States [U.S.] Food and Drug Administration [FDA] revealed epidemiological outbreak data repeatedly identified five major risk factors related to employee behaviors and preparation practices in retail and food service establishments as contributing to foodborne illness which included improper holding temperatures. Time/Temperature Control for Safety Food (TCS) means a food that requires time/temperature control for safety (TCS) to limit pathogenic microorganism growth or toxin formation. Per a review of the 2022 Food Code Time/Temperature control for food safety shall…

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 of the food and nutrition department, and interviews with staff it was determined that the facility failed to ensure that essential mechanical dietary equipment was in safe operating condition. Findings include: Interview with the Food Service Director, Employee E3, on September 10, 2024, at 12:10 p.m. revealed the steam tables in the main kitchen were broken. Continued interview with the Food Service Director, Employee E3, revealed the steam table has been broken since June 2024. Observations during the lunch time meal service on September 10, 2024, at 12:15 p.m. revealed dietary staff utilized a tray line meal system and plated resident meal trays in the main kitchen before delivering trays to the residents in their rooms. Observations confirmed the steam tables were broken and not being used. Continued observations revealed as an attempt to keep trays of food warm during tray line service, dietary staff had pans of food placed directly on top of the stove top gas burners with the gas burners turned on low. Continued observations revealed a flat top griddle…

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

Based on observations, and resident and staff interviews it was determined that the facility failed to provide food and drink that was served palatable temperatures for three of four residents interviewed (Resident R2, R3, and R4). Findings Include: Interview on September 10, 2024, at 1:40 p.m. with alert and oriented Resident R2 revealed the coffee and food is served cold. Interview with September 10, 2024, at 1:42 p.m. with alert and oriented Resident R3 revealed the food is served cold and on September 9, 2024, Resident R3 did not eat lunch because the food was so cold and not palatable. Interview on September 10, 2024, at 1:45 p.m. with alert and oriented Resident R4 revealed the food is always served cold. A test tray was completed during the lunch time meal on September 10, 2024, at approximately 1:25 p.m. with the Food Service Director, Employee E3, which revealed the following temperatures: [NAME] 114 degrees Fahrenheit (F), Baked Chicken 111.8 degrees F, Pureed Ziti 96.3 degrees F, Pureed Vegetable 96.6 degrees F, and Mashed potatoes 100 degrees F. A taste test of the above…

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 interviews with resident and staff, review of facility policy and grievances, it was determined that the facility failed to make prompt efforts to resolve resident's grievances for one of four resident records reviewed (Resident R2). Findings include: Review of the facility's policy titled, Grievance/Concern Management, effective February 2021 states, The residents have a right to present concerns, recommend changes in policies and services. These rights include the right to prompt efforts by the facility to resolve residents' concerns. The same policy states that the Nursing Home Administrator (NHA) is responsible for oversight of the concern process. In addition, the Social Services Director in collaboration with the NHA will be the Grievance Officer at the facility. Review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of Chronic Obstructive Pulmonary disease (respiratory disease), high blood pressure, and major depression…

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 interview with staff, it was determined that the facility failed to report a serious injury sustained by a resident for one of four clinical records reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of cerebral infarction (stroke) affecting left sided weakness. Review of Resident R1's admission Minimum Data Set (MDS-an assessment of resident's needs) dated May 2, 2024, assessed the resident with one sided upper and both sides lower body impairment. Continued review of the MDS revealed that the resident required substantial/maximum assistance to roll left and right. The resident was assessed as dependent (helper does all the effort) when lying to sitting on the side of the bed. Resident R1's nursing note dated July 12, 2024, revealed that the resident fell from his bed, placed in the highest position during care by staff (Nursing Assistant, (NA) Employee…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, and interviews with staff, it was determined that the facility failed to develop and implement comprehensive person-centered plans of care in a timely manner for one of four resident records reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of cerebral infarction (stroke) affecting left sided weakness, deep vein thrombosis (blood clot), high blood pressure, lack of coordination, anxiety disorder, bipolar ( mental health condition marked by intense mood changes), morbidly obese and weakness. Review of Resident R1's admission MDS (an assessment of resident's needs) dated May 2, 2024, indicated the resident was cognitively intact. The resident was assessed with one sided upper and both sides lower body impairment. The reisdent needed substantial maximum assistant (helper does more than half the effort) of one staff member for toileting, showering/bathing,…

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

Based on the observations, review of clinical records, facility policies, and interview with staff, it was determined that the facility failed to ensure that a resident received necessary equipment to aide with mobility for one of 4 residents reviewed. (Resident R1). Findings include: Review of Resident R1 clinical record revealed an admission date of April 25, 2024, diagnosed with a cerebral infarction (stroke) affecting left sided weakness, deep vein thrombosis (blood clot), high blood pressure, lack of coordination, anxiety disorder, bipolar ( mental health condition marked by intense mood changes), morbidly obese and weakness. Review of Resident R1 admission MDS (an assessment of resident's needs) dated May 2, 2024, indicated the resident was cognitively intact, one sided upper and both sides lower, body impairment, and needed substantial maximum assistant (helper does more than half the effort) of one staff member for toileting, showering/bathing, dressing and personal hygiene. Review of Resident R1's clinical record revealed a plan of care was developed due to the residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility security camera footage, clinical record reviews, review facility policy, review of facility documents and staff interviews, it was determined that the facility failed to ensure that one of one resident reviewed was free from physical restraints (Resident R1) Findings include: Review facility policy on Restraint Management revealed that the facility will promote quality of life and resident centered care. Restraints will be used only when necessary to treat a medical symptom and not used for staff convenience. The least restrictive restraint for the shortest duration of time will be applied to assist the resident in reaching their highest level of physical and psychological well-being. The facility will document and demonstrate the presence of specific medical symptoms that requires the use of the restraint to treat the cause of symptoms. The interdisciplinary team will assess medical symptoms by evaluating resident's condition, circumstances, and environment. The facility recognizes…

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 facility documents and interview with staff, it was determined that the facility failed to ensure that a resident who exhibited behavior problems was provided with appropriate behavioral management to de-escalate the inappropriate behavior (Resident R1). Findings include: Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses of Anoxic Brain Damage (a damage in the brain caused by lack of oxygen), Vascular Dementia, Lack of Coordination, Unsteadiness on Feet, Anxiety Disorder. Review of Resident R1's admission Minimal Data Set (MDS- assessment of care needs) dated April 19, 2024, section C0500 BIMS (Brief interview for mental status) score revealed that resident scored 06 suggesting severe cognitive impairment. Review facility training materials on Preventing and Managing Catastrophic Reactions revealed that Catastrophic Reaction is defined as emotional outbursts, sometimes accompanied by physical-action behavior…

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

Based on review of facility policies, observations, and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: A review of facility policy titled, Policy and Procedure under the heading, Storage, indicated that refrigerators are equipped with thermometers and checked by staff daily to ensure maintaining temperature at or less than 41 degrees Fahrenheit (F) and freezer at or less than 10 degrees F. A review of policy titled, Storage dated 2021, indicated that the refrigerator thermometer should be placed in the warmest area in the refrigerator unit, near the door. A tour of the Food Service Department was conducted on January 16, 2024, at 11:13 a.m. with the Food Service Director (FSD), Employee E19. Observations in the pantry refrigerator revealed the following items were expired, dated January 14, 2024: pureed sweet potatoes, pureed turkey, mashed potatoes, and mushrooms. Further observations revealed A container of cooked…

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

Based on the review of facility records, observations and interviews with resident and staff, it was determined that the facility failed to ensure a safe and comfortable environment for resident and staff for two of two floors (Second floor dining room and First Floor Rehab). Finding Include: Review of facility policy Physical Environment dated January 1, 2020, revealed that A safe, clean, comfortable, and home-life environment is provided for each resident/patient, allowing the use of personal belongings to the greatest extent possible. Sufficient space and equipment in dining, health services, recreation, and program areas are provided to enable staff to provide resident/patients with needed services. All essential mechanical, electrical, and resident/patient care equipment is maintained in safe operating condition through the facility's Preventative Maintenance Program Interview with Resident R297 on January 18, 2024, at 10:50 a.m. revealed that the first floor rehab room was cold and he was wearing three layers of clothes. He stated staff should put the temperature up because he…

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

Based on the review of clinical records, facility investigation, review of facility policy and interviews with resident and staff, it was determined that the facility failed to treat residents with respect and dignity for one of 20 residents reviewed. (Resident R22) Findings Include: Review of an updated facility policy Resident Rights-Resident [NAME] of Rights revealed that No resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law . Every resident of a facility shall have the right to: Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. Retain and use his or her own clothes and other personal property in his or her immediate living quarters, so as to maintain individuality and personal dignity, except when the facility can demonstrate that such would be unsafe, impractical, or an infringement upon the rights of other residents. Interview with Resident R22 on January 16, 2024, at 11:32 a.m. stated couple months ago, he was sexually assaulted by three…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to provide written notice, including reason for transfer before a resident's room was changed for one of 20 residents reviewed (Residents R77). Findings Include: A review of facility policy titled, Room Change Notification dated February 2021, indicated that the facility must contact the resident/ resident representative when a room change is being considered and must document the reason for room change. Review of Resident R77's Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated November 13, 2023, revealed Resident R77 was admitted to the facility on [DATE]. Continued review of Resident's MDS revealed a BIMS (Brief Interview for Mental Status) score of 11, indicating moderate cognitive impairment; and had a POA (a power of attorney). Review of facility investigation dated July 2, 2023, revealed that Resident R77 was moved…

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 personnel records, interviews with staff and reviews of facility policies and procedures, it was determined that the facility failed to initiate and complete a federal criminal background check four of six employee records reviewed (Employees E14, E16, E21, and E22) and failed to initiate and complete abuse training for one of six employee records (Employee E22). Finding include: A review of the policy titled Abuse, Neglect and Misappropriation the facility strives to reduce the risk of resident abuse, neglect, and misappropriation. The policy also indicated that Potential employees are screened for a history of abuse, neglect, or mistreatment of residents. Screening will consist of, but may not be limited to, inquiry to state licensing authorities if applicable, inquiry into state nurse registry, references checks and criminal background checks. A review of personnel files revealed Employee E14, nurse aide was hired on December 13, 2023; Employee E16, Licensed nurse, was hired on October 10, 2023; Employee E21, nursing aide, was hired on December 15, 2023, and…

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

Based on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner for two of 20 residents reviewed (Resident R77 and R30). Findings include: Review of Resident R77's clinical record revealed that the resident was transferred to the hospital on July 2, 2023, after a resident-to-resident altercation which occurred on July 2, 2023. Further review of Resident R77's clinical record failed to reveal documentation of a written hospital transfer notice provided by the facility to Resident R77's responsible party and the Office of the State Long-Term Ombudsman. Review of Resident R30's clinical record revealed that the resident was transferred to the hospital on April 12, 2023, related to change in condition. Further review of Resident R30's clinical record failed to reveal documented evidence of a written hospital transfer notice provided by the facility to Resident R30's responsible party and the Office 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 interview, it was determined that the facility failed to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for two of 20 residents reviewed. (Resident R77 and R30) Findings include: Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R77 dated November 13, 2023, revealed Resident R77 was admitted to the facility on [DATE]. Continued review of Resident's MDS revealed a BIMS (Brief Interview for Mental Status) score of 11, indicating moderate cognitive impairment; and had a POA (a power of attorney). Review of Resident R77's clinical record revealed that the resident was transferred to the hospital on July 2, 2023, after a resident-to-resident altercation which occurred on July 2, 2023. Further review of Resident R77's clinical record revealed that there was no documented evidence that resident's representative was provided 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 interviews and the review of clinical records, it was determined that the facility failed to ensure that the State mental health authority and/or the State intellectual disability authority was notified of a significant change in resident's mental health status which required admission into a psychiatric facility for 2 out of 22 residents reviewed (Resident R197 and Resident R85). Findings include: Review of the June 2023 physician orders for Resident R197 include the following diagnosis: chronic kidney disease (a gradual loss of kidney function over time); hypertension (high blood pressure); diabetes (a disease that occurs when your blood sugar, is too high) intellectual disabilities (a term for when a person has limited mental abilities and skills for daily life), and schizophrenia (a mental disorder in which people interpret reality abnormally). Review of a nursing note dated April 10, 2023 at 10:44 p.m. revealed that Resident R197 was hospitalized and sent out for changes in her behavior and escalated aggression. Resident R197 was subsequently admitted into a…

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

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that a care plan was updated related to nutrition for one of two residents reviewed (Resident R30). Findings include: Review of Resident R30's weight records indicated that on July 7, 2023, the resident weighed 105 pounds. On December 7, 2023, the resident weighed 93 pounds; indicating a 11.43% weight loss in five months. Review of physician orders revealed multiple orders for nutritional supplements, including Boost Plus; Prostat; and Magic Cup. Further review revealed Resident R30 was ordered a regular diet on May 5, 2023; regular texture, and regular (thin) consistency liquids. Review of nutrition notes revealed a note dated, December 15, 2023, which indicated that Resident R30's representative was aware of resident's weight loss and suggested that Resident R20 likes to have finger foods like sandwiches and rolls including chicken in a roll, peanut butter sandwiches, or ham sandwiches to prevent further weight loss. Review of Resident R30's current care plan,…

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

Based on the review of facility immediate jeopardy action plan, clinical records, facility policies, observations and interview with staff and residents, it was revealed that the facility failed to ensure that a resident received a care and services in accordance with the comprehensive person-centered care plan and facility immediate jeopardy action plan. (Resident R27) Findings Include: Review of an undated facility policy Suicidal Ideation Identification and Guidance revealed that Evaluate resident environment for safety; remove and store objects which could be used for self-harm. Objects to consider for removal may include but not be limited to: a. Ligatures - belts, neckties, call light cords, shower hose, oxygen tubing, tube feeding tubing, IV tubing, cables to the TV or other electronics, wire coat hangers etc. b. Sharp objects such as pens, pencils, knives, scissors, utensils for eating, razor blades, etc. c. Personal care supplies that may be poisonous if ingested d. Educate resident/resident representatives about reviewing new personal items with staff upon receipt in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record, and staff interview, it was determined that the facility failed to ensure the one of one resident ordered enteral feeding was properly position during care to prevent potential complications associated with tube feedings (Resident 47). Findings include: Review of Resident R30's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dysphasia (language disorder that affects the ability to produce and understand spoken language), hemiplegia (paralysis of one side of the body), and aphasia (comprehension ad communication disorder). Review of physician order dated December 21, 2023, revealed an Enteral feed order: Glucerna 1.2 Cal. Continuous via tube to infuse at a rate of 60 mL/hr. total volume of 1320 mL infused in 24 hours. May turn off for care/services . Observations conducted on January 17, 2024, at 11:54 a.m. reveled Nurse Aide, Employee E18 was providing care (bed bath) for Resident R47. Further observations revealed…

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

Based on observation, review of clinical record and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and services for one of 22 residents reviewed (Residents R61). Findings include: Review of Resident R61's clinical record revealed the resident was diagnosed with tracheostomy status (procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck). Review of Resident R61's physician's orders dated March 29, 2023, revealed the tracheostomy size 6. Humidified Oxygen Per trach PRN (as needed) 2 liters. Change trach collar, mask, and oxygen weekly as well as PRN. Further review of Resident's R61's clinical record revealed a physician's assessment and plan dated on December 5, 2023, to start trach mask with humidifier. Observation of Resident R61 conducted on January 22, 2024, at 9:35 a.m. revealed that the trach /oxygen nasal cannula to the oxygen concentrator did not have a date affixed. Extra 6.5 and 7 tracheostomy was observed in the trach care station in resident's room.…

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.

The facility failed to ensure that performance reviews for nursing assistants were completed annually to ensure that in-service education was based on the outcomes of the performance reviews for 1 out of 3 nursing assistants reviewed (Employee E30) and failed to ensure the completion of 12 hours of inservice for 3 out of 3 nurse aides reviewed (Employee E30, E31 and E32). Findings include: Review of the documentation provided from the facility revealed there was no annual performance evaluation for Employee E30. Review of training records for Employee E30, E31 and E32 did not show evidence that nurse aides were provided with 12 hours of training per year was conducted, as required. During an interview with the Director of Nursing on January 22 at 2:15 p.m. the Director of Nursing confirmed that she could not provide documentation to show evidence that the facility completed the required annual performance reviews for the above referenced nursing assistant, or the annual 12 hours of inservice training for the above referenced nursing assistants. 28. Pa. Code 201.19(d)(1) Personnel…

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

Based on review of facility policy, observation, review of clinical records, interview with staff and residents it was determined that the facility failed to ensure that medications were administered in accordance with professional standards for one of 25 residents reviewed. (Resident R56) Findings include: Review of facility policy on Medication Administration dated September 2018, revealed that Medications are administered as prescribed in accordance with manufacturers specification, good nursing principles, and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of the prescriber. Review of physician order for Resident R56 dated September 8, 2023, revealed an order for Simethicone 80 (milligrams mg) tablet every 6 hours as needed for gas pain. Interview with Resident R56 on January 16, 2024, at 12:00 p.m., stated, she had stomach pain due to gas and she requested as needed medications to the nurse. She stated she requested the medication after the breakfast around 9:00 a.m. Resident also stated she asked 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, staff interviews, and review of facility policy, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for one of two medication carts and two of one medication storage rooms observed (first floor cart A and second floor medication storage room). Findings include: Review of facility policy Storage of Medication, dated [DATE], revealed that The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. Observation of the first-floor cart A with Employee E35, Licensed Practical Nurse, revealed that the medication cart contained undated and expired insulin. There were two insulin glargine pens without open date or discard dates. There were one Trulicity pen…

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

Based on review of facility records, job descriptions, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper procedures were followed in the facility related to ensuring that hazardous materials were not accessible to residents in one nursing unit. This failure resulted in Resident R27 with documented history of behavioral issues and suicidal ideation obtained a twin blade disposable razor and was observed swinging the razor in the dining room while residents were within 2-3 feet close to the resident. The facility's failure placed Resident R27 who had a history of suicidal ideation and behavioral issues as well as other residents on the second floor at risk for serious injury and resulted in immediate jeopardy situation. Findings include: Review of the job description for the Nursing Home Administrator (NHA) revealed that The Nursing Home Administrator as a member of The Board of Managers of Operator is responsible and accountable for 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 review of facility policy, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices related to hand washing during medication administration for one 1 of 2 staff observations reviewed. (Resident R72) Findings include: Review of facility policy on Medication Administration dated September 2018, revealed that Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, parental, enteral, rectal, and vaginal medications. Hands are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulation and facility policy. Note: Soap and water should be used after contact with resident with Clostridium difficile as microbial sanitizer does not kill the spores produced by Clostridium difficile, which may result in the spread of the infection. Observation of medication administration by Employee E35, Licensed Practical Nurse on January 22, 2024, 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.

Based on observations, interviews with staff and residents and review of facility policy, it was determined that the facility failed to ensure that call bells were within reach for one of 25 residents reviewed. (Resident R36). Findings include: Review of care plan for Resident R36 dated January 26, 2020, revealed that the resident had an Activities of Daily Living (AdL) self-care deficit, and he could not complete ADL tasks independently and required staff assistance. Review of a care plan intervention revealed an intervention, call bell within reach in the room/bathroom/shower room and remind to use. Observation of Resident R36's room on January 16, 2024, at 12:07 p.m., revealed that the call bell was tangled with resident's beds electric cord on the floor next to the bed. Resident R36 was laying in the bed and was unable to reach the call bell. There was a hand bell sitting on the bed side table which was away from resident's reach. Observation of Resident R36's room on January 17, 2024, at 11:00 a.m., revealed that the call bell was tangled with resident's beds electric cord 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 observation and interviews with staff, it was determined that the facility failed to maintain a clean and safe environment for residents on two of two floors. (1st and 2nd floor). Findings include: A tour of the facility was conducted on 1st and 2nd floor nursing units on November 8, 2023 at 10:30 a.m. which revealed the following: Observations in room [ROOM NUMBER] revealed the corner of the wall next to the wardrobe at the entrance was cracked and the plaster was missing, and the sharp steel corner was exposed. Observations in room [ROOM NUMBER] revealed the corner of the wall next to the wardrobe at the entrance had a rough white patching substance on the wall which was not sanded smooth or painted to match the surrounding wall, the baseboard next to the A bed was missing, and bed A's overbed light was not working. Further observation revealed that the bedside table next to the B bed was missing the middle drawer, and C bed's dresser was broken and missing the top drawer. Observations outside room…

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 of the resident communication system on the first and second floor nursing units, interviews with staff and residents, it was determined that the facility was not adequately equipped to relay a call directly to a centralized staff work area from each resident's bedside on two of two nursing units. (First and Second Floor) Findings include: Interviews with alert and oriented Residents: R1, R3, R4, R5 R6, R7, R8, R9, R10, R11, R12, R13 R14 and R15, between 1:00 p.m. and 2:00 p.m., on October 30, 2023 revealed that their calls for staff assistance were not being answered in a timely manner. Residents reported that the communication system was not sending a visual or audible message to the centralized nurses' station. Observations of the resident communication system on the first and second floor nursing units between 2:00 p.m. and 2:30 p.m., on October 30, 2023 revealed that all portions of the resident communication system were not functioning. The call light system for resident room [ROOM…

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 meal tray evaluation, observations of the food and nutrition department and interviews with staff and residents, it was determined that each resident was not receiving flavorful, palatable, attractive foods and beverages, served at safe and appetizing temperatures. for one of two nursing floors. (Second Floor nursing unit) Findings include: Observations of the food and nutrition department on October 30, 2023, revealed that the food service equipment (lowerator) used to warm ceramic plates for meal tray service and transport of hot foods from the main kitchen to the nursing units was luke warm to touch. Further observations of the food and nutrition services department on October 30, 2023, revealed that there was no thermal system (pellet) system in use to ensure that hot foods were being served to the residents at safe and appetizing temperatures for breakfast, lunch and dinner daily. Interview with the Director of Dietary Services, Employee E6, at 10:00 a.m., on October 30, 2023 revealed that the proper electrical outlet for the food service equipment was not available…

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.