Norriton Square Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record review, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure a resident was free from misappropriation related to missing medication for one of three residents reviewed (Resident R1). Findings include: Review of facility policy, Abuse Prohibition dated October 24, 2022, revealed, Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation for all residents. Continued review revealed, Misappropriation of patient property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patient's belongings or money without the patient's consent. Review of Resident R1's Annual MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated June 4, 2025, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including cancer and chronic pain. Continued review revealed that…

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

Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for two of three residents reviewed (Residents R1 and R2). Findings include: Review of facility policy, Management of Controlled Drugs dated January 31, 2025, reveled, A complete count of all Schedule II-IV controlled substances is required at the change of shifts per state regulation or at any time in which the narcotic keys are surrendered from one licensed nursing staff to another. The count must be performed by two licensed nurses. Review of Resident R1's physician orders revealed an order, dated August 29, 2025, for oxycodone (opioid pain medication) 5 m.g (milligrams) give one tablet two times a day for chronic pain. Review of Controlled Substance Inventory Count Sheets revealed that Employee E7, licensed nurse, worked on the 3A medication cart on August 29, 2025, from 3:00 p.m. through August 30, 2025, at 7:00 a.m. During the 11:00…

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.

Based on review of facility policies, review of facility documentation, review of personnel files and interviews with staff, it was determined that the facility failed to ensure that nursing staff received training on abuse, neglect, exploitation and misappropriation of resident property as required for two of three nursing staff reviewed (Employees E4 and E8). Findings include: Review of facility policy, Abuse Prohibition dated October 24, 2022, revealed, Training and reporting obligations will be provided to all employees through orientation, code of conduct training and a minimum of annually. Interview on September 4, 2025, at 10:19 a.m. Employee E4, agency licensed nurse, stated that it was her first day working at the facility. Employee E4, agency licensed nurse, stated that when she arrived for her shift, she was given report from the night nurse and showed around the nursing unit. Employee E4, agency licensed nurse, stated that she completed some online training prior to working at the facility but was unable to specify what topics were reviewed. 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.

Based on observation, and staff interview, it was determined that the facility failed to ensure that essential equipment was maintained in safe and operating conditions related to the refrigerators in dining rooms for two of two floors reviewed. (Second and Third Floors). Findings Include: An initial tour of the third floor Dining Room was made on 11:55 a.m. on July 2, 2025. Observation of the dining service area for the third floor revealed the ice machine was leaking and had a towel on floor that was saturated as well as visible water around the area, this was confirmed by the Dietary staff, Employee E4. When asked what happens when there is a leak, Employee E4 stated, well, I do not know, that is a different department. Further review of the service area revealed two refrigerators not currently operable. One refrigerator underneath the counter had a Do Not Use sign on it and it had wet condensation on the outside of it. The other clear display refrigerator was in the front of the service area. Employee E4 stated they have not been working. An initial tour of the second floor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a review of facility policy, it was determined that the facility failed to store food, in accordance with professional standards for food service safety. Findings Include: Review of facility Policy titled, Food Storage: Cold Foods, last revised February 2023 states, Policy Statement- All Time/Temperature Control for Safety (TSC) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures- 5. All foods will be stored wrapped or covered in containers, labeled and dated, and arranged in a manner to prevent cross contamination. A tour of the facility kitchen area was conducted on July 2, 2025, at 10:05 a.m. with the Director of Dining Employee E3. During observation several items were observed in the walk-in refrigerator undated or labeled improperly. The first item was a container of prepared shredded carrots that had a labeled date of June 10, 2025 but no Use By date. When asked if the food is supposed to be labeled Employee E3 stated, I was told that we didn't need 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.

Based on review facility policy, review of facility documentation, review of clinical records, interview staff, it was determined that the facility failed to ensure that a resident was free of neglect related to provision of incontinence care for one of twelve residents reviewed. (Resident R12) Findings: Based on review of facility policy titled Abuse Prohibition dated October 24, 2022, revealed the center prohibits abuse mistreatment, neglect, misappropriation of resident property, exploitation for all patients this is includes but not limited to freedom from corporal punishment and voluntary seclusion and any physical or chemical restraint, potential hires, training of employees, prevention of occurrences, identification of possible incidents or allegations which need investigation. Review of facility policy titled Neglect and Abuse revealed neglect is defined as a failure, in difference, or disregard of the center, its employees or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility policy, review of facility documentation, review of clinical records, interview with residents and staff, it was determined that the facility failed to ensure adequate number of nurse aides to meets the needs of residents on one of two nursing floors (2nd Floor) one of twelve residents reviewed. (Resident R12) Findings: Review of Resident R12's clinical record revealed the resident had diagnosis of non-displaced intertrochanteric fracture of left femur (minimal displacement of the upper part of the left thigh bone), chronic embolism and thrombosis of vein (blood clot in the veins) diabetes with neuropathy (nerve damage caused by diabetes), personal history of TIA (transient ischemic attack temporary blockage of blood flow to the brain, minor stroke). Review of Resident R12's admission Minimum Data Set (MDS- assessment of resident's needs) dated February 14, 2025 revealed that the resident was assessed with a BIMS (brief interview of mental status) score of 6, which indicated that the resident had severe cognitive impairment. Review of Resident R12'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.

Based on observations, clinical record review, and interviews with staff and residents, it was determined that the facility failed to provide reasonable accommodations of needs relating to a bariatric bed and a functioning heater for two of 31 residents reviewed.(Residents R251 and R248) Findings include: Review of Resident R251's Minimum Data Set (MDS-federal mandated assessment for all residents) dated February 12, 2025 revealed that Resident R251 was admitted into the facility on February 6, 2025 with diagnosis' including respiratory failure (respiratory system cannot maintain normal levels of oxygen and carbon dioxide in the body), chronic congestive heart failure(long term condition , the heart is unable to pump blood effectively), type 2 diabetes(condition that occurs when blood glucose is too high) and morbid (severe) obesity (health condition that results from abnormally high body mass that is diagnoses by having a body mass index(BMI) greater then 40). Review Resident R251's lift transfer evaluations dated February 6, 2025, revealed Resident R251's weight dated February 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 clinical record reviews and interviews with staff, it was determined that the facility failed to follow physician orders related to diabetes management for one of 24 residents reviewed (Resident R24). Findings include: Review of Resident R24's Annual MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated January 20, 2025, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose). Review of physician orders for Resident R24 revealed an order, dated May 23, 2023, to check the resident's blood glucose level and notify the physician if greater that 400. Review of Resident R24's blood glucose levels revealed the following: On January 24, 2025, at 4:36 p.m. blood glucose level was 416; On January 1, 2025, at 8:32 p.m. blood glucose level was 416; On December 29, 2025, at 4:18 p.m. blood glucose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interviews, and review of clinical records, it was determined that the facility failed to ensure that weekly weights were obtained for two out of twenty-four residents reviewed with a history of weight loss (Resident R39 and Resident R74). Findings include: Review of Resident R39's clinical record revealed that Resident R39 was admitted to the facility on [DATE]. Review of Resident R31's clinical record revealed the diagnoses of Huntington's Disease (neurogenerative disease), Dysarthria following Non-traumatic Sub-arachnoid Hemorrhage (cranial bleed), Dysphagia (inability/difficulty swallowing). Review of Resident R39's clinical record revealed a physician's order dated August 21, 2023 for the resident to be weight monthly every day shift starting on the 1st and ending on the 5th every month. Review of Resident R39's weight record revealed the following weight values in pounds (lbs.): May 1, 2024 - 150.4 lbs., June 19, 2024 - 135 lbs., July 2024 - no values recorded, August 6, 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 observation, review of facility policy and interviews with staff, it was determined that the facility did not maintain respiratory equipment according to professional standards of practice for two of twenty-four residents reviewed. (Resident R17 and Resident R56) Findings: Review of facility policy entitled Oxygen: Concentrator revealed that An Oxygen concentrator extracts oxygen molecules from room air. It can be used for low oxygen flows rates (i.e. 1-4 L/min). #9. Label, date, and attach pre-filled humidifier bottle, if applicable. Review of Resident R17's clinical record revealed that Resident R17 was admitted to the facility on [DATE], with most recent readmission of February 2, 2025. Further review of Resident R17's clinical record revealed the following diagnoses Chronic Diastolic Congestive Heart Failure (excessive body fluid caused by a weakened heart muscle) and Atrial Fibrillation (irregular and rapid heart beat). Review of Resident R17's physician's orders revealed an order for: Oxygen at 2…

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

Based on observation, review of facility policies and interview with staff, it was determined that the facility failed to ensure that a medication cart was kept locked when not in use and that medications were properly stored for two of two carts. (Medication Cart A and Medication Cart B) Findings include: Review of facility documentation titled Medication Storage dated January 2025 revealed that medication storage and biologicals are stored properly to support safe effective drug administration. The pharmacy dispenses medication that meets state and federal labeling requirements, medications are to remain in containers and stored in a controlled environment this may include such containers as medication carts, medication rooms, and medication cabinets. Licensed nurses, pharmacy staff and those lawfully authorized to medications are to have access the medication carts. Medication should remain locked with not in the use or attended to by persons with authorized access. The medication supply shall be accessible only to licensed nursing personnel pharmacy personnel or staff members…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews with residents and staff, it was determined that the facility did not provide foods in accordance with resident preferences for three of 24 residents reviewed (Residents R43, R42 and R19). Findings include: Review of resident R 43's quarterly minimum data set (MDS- a federal mandated assessment of all residents) December 24, 2025, revealed resident r 43 was admitted into the facility August 14, 202 with diagnosis' including coronary artery disease(CAD-Plaque buildup in the hearts arteries), heart failure, anxiety(disorder of episodes of intense anxiety and fear), schizophrenia(mental disorder characterized hallucinations, delusions and disorganized thinking and behavior). Resident 43 requires setup and cleanup assistance for dining. Review of resident R43's physician orders dated October 23, 2024, revealed an order for lacto- ovo vegetarian diet (a diet that excludes meat, poultry, and fish, but allows eggs and dairy products) Review of resident R 43 care plan revealed that resident R 43 is at nutritional risk related to underweight bmi(body mass…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a review of facility procedures, it was determined that the facility failed to store food, in accordance with professional standards for food service safety. Findings include: Review of facility Policy entitled Receiving revealed that under Policy Statement: Safe food handling procedures for time and temperature control will be practiced in transportation, delivery and subsequent storage of all food items. Under section Procedures: #5. All food items will be appropriately labelled and dated either through manufacturer packaging or staff notation. #7. All non-perishable foods and supplies will be stored appropriately Observation of the general kitchen area during the tour of the kitchen conducted on February 9, 2025, at 8:59 am revealed two metal shelving units against the wall of the kitchen. Observation of one of the shelving units revealed that the middle shelf of the metal shelving unit had a plastic bin with white powder. Further, the plastic bin was labelled breadcrumbs with label indicating opened 12/19/24 and use by 1.19.25.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility documentation, review of personnel files and interviews with staff, it was determined that the facility failed to ensure that staff were licensed and registered in accordance with State laws for three of 11 personnel files reviewed (Employees E21, E17 and E16). Findings include: Review of facility documentation submitted to the Pennsylvania Department of Health on [DATE], at 4:33 p.m. revealed that on [DATE], the facility discovered that Employee E21, RN (registered nurse), was working with an expired nursing license and that the license had expired on [DATE]. The facility provided education to Employee E21, RN, including its policy that it is the responsibility of the employee to maintain an active nursing license at all times and that if the license is not current that the employee may not work until the license is active. Employee E21, RN, subsequently reactivated her nursing license on [DATE]. In response to the above incident, that facility conducted an audit of all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 upon observation, interviews and review of clinical records and facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of multi-drug resistant organism (MDRO) transmission for one of 31 residents reviewed. (Resident R35) Findings include: Review of facility policy titled Enhanced Barrier Precautions revised December 16, 2024, revealed enhanced barrier precautions (EBP) are an infection control intervention designed to reduce the transmission of novel or multidrug resistant organisms. It employs targeted personal protective equipment (PPE) during high contact resident activities. This includes all residents with any other following infection or colonization with targeted MDRO, chronic wounds, indwelling medical devices (eg: central line, urinary catheter, feeding tube, tracheotomy). The use of personal protective equipment (PPE)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interviews with staff it was determined that the facility failed to ensure that nurse aides received at least 12 hours of in-service education per year as required for one of six nurse aide personnel files reviewed (Employee E9). Findings include: Review of Employee E9's personnel file revealed that the employee was hired on June 20, 2019, as a nurse aide. Continued review revealed that from February 11, 2024, through February 10, 2025, Employee E9, nurse aide, completed only two courses of annual education: hand hygiene and personal protective equipment. Interview on February 10, 2025, at 12:52 p.m. the Nursing Home Administrator confirmed that Employee E9, nurse aide, had not completed 12 hours of annual in-service education as required. 28 Pa Code 201.19(7) Personnel policies and procedures 28 Pa Code 201.20(a) Staff development

Based on observations, staff interviews, and the review of facility documentation, it was determined that the pharmacy failed to timely respond to the facility inquiry of a possible error in the dispensing of a medication for 1 out of 4 residents reviewed (Resident R1). Findings include: Review of the facility policy, Provider Pharmacy Requirements, with a date of January 2023 indicated that the provider pharmacy agrees to perform pharmaceutical services that include providing medications packaged in accordance with the nursing care center's need and equipment requirements and accurately dispensing prescriptions based on authorized prescriber orders. Review of the September 2024 physician orders indicated that Resident R1 had diagnosis that included cerebral infarction (a stroke); dysphasia (difficulty swallowing); aphasia (brain disorder that affects speaking and understanding language); heart disease, and hypertension (high blood pressure). Continued review of the September 2024 physician orders included a physician's order dated January 5, 2024, and monthly thereafter, for the…

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

Based on interview with residents and staff and review of facility documentation, it was determined that facility did not ensure residents were treated with dignity and care in a manner and in an environment that promotes the enhancement of their quality of life related to fresh air breaks for thirteen of 19 residents reviewed (R6, R37, R45, R70, R36, R25, R54, R81, R26, R17, R64, R87, R10) Findings include: On April 3, 2024, at 10:30 a resident council meeting was held with 12 alert and oriented residents (R37, R45, R70, R36, R25, R54, R81, R26, R17, R64, R87, R10) all reported that they have a strong desire to have fresh air brakes during the day. All residents could not recall when they were allowed to go outside besides the leave of absence (LOA) visits upon approval. Three months of Resident Council minute notes were reviewed, and it was noted that on February 29, 2024, that residents requested to have fresh airtime. Four months of activity calendar was reviewed and there were no outside activities noted. On April 3, 2024, at 11:28 a.m. an interview was held with the activity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records, and interviews with residents and staff, it was determined that the facility failed to maintain sufficient nursing staff levels to provide nursing care and services for five of 19 residents reviewed (Residents R80, R78, R90, R73, R198 ). Findings include: On April 2, 2024, at 11:39 a.m. observation was taken place with Resident R80 who was in bed sleeping and there was a strong odor of fecees. On April 2, 2024, at 12:02 p.m. an family interview was held with a Resident R78 who is non-verbal. Family member was observed doing morning care to the resident due to lack of staffing. It was additionally noted that a family member visits 2-3 times a week, and there was an expectation from the staff for her to assist with morning care. On April 2, 2024, at 12:12 p.m. Resident R90 reported facility is short on staffing and need more people. On April 2, 2024, at 12:24 p.m. Resident R73 reported that she did not get a shower for a week and half due to lack insufficient staffing. I returned form leave of absence (LOA) from Easter holiday and did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff interview, it was determined that the facility failed to maintain the confidentiality of a resident's medical information on one of two nursing units (third floor). Findings include: Review of facility policy, Health Insurance Portability and Accountability Act (HIPPA) Compliance, reviewed and revised May 1, 2022 revealed, Policy: The Company has a long standing committment to protecting the privacy of Protected Health Information. The Company also has a further obligationto be compliant with the privacy standards contained in the Health Insurance Portability and Accountability Act of 1996 (HIPPA). The Company has developed policies and procedures to meet the following HIPPA requirements to: 4. Secure patient records containing protected health information such that they are not readily accessible by unauthorized parties. Observation on April 4, 2024 at 9:10 a.m. during Medication Administration revealed Employee E10 picking up the medication cup and proceeding to enter Resident R74's room to deliver medication. Employee E10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's policies, review of clinical record and interviews with staff, it was determined that the facility failed to ensure that one resident was free from misappropriation of medication for one of 19 residents reviewed (Resident R74). Findings include: Review of facility policy and procedure: Abuse Prohibition, reviewed and revised October 24, 2022, revealed, Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all patients. Misappropriation of patient property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patient's belongings or money without the patient's consent. Physician orders for Resident R23 included an order for the resident to receive Eliquis (a blood thinner) 5 milligrams twice per day. Observation of medication administration on April 4, 2024 at 9:40 a.m with Employee E10, licensed nurse, revealed Employee E10 preparing medication for Resident R23 and determining that there was no Eliquis 5 mg available in his drawer. Employee E10 stated, I…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, a review of select facility's policy, clinical records review, and staff interviews, it was determined that the facility failed to ensure ongoing evaluation of a resident's need and use of restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom for one resident out of 19 sampled residents. (Resident R6) Findings include: A review of a facility policy titled Restraints -Use of, revised on June/15/2022 revealed Patients have the right to be free from any physical or chemical restrains imposed for purposes of discipline or convince, and not required to treat the patient's medical symptoms. Physical Restrain is defined as any manual method, physical or mechanical devise, equipment, or material that meets all of the following criteria: Is attached or adjacent to the patient's body, Cannot be removed easily by the patient, and restricts the patient's freedom of movement or normal access to their body, It further states Patients with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 'Based on review of facility policy and clinical records, and staff interview it was determined that the facility failed to develop a comprehensive care plan for three of 19 residents reviewed (Residents R6, R83, R86). Findings include: Clinical record review revealed that Resident R6 was admitted to the facility on [DATE], with the diagnosis of encounter for surgical after care following surgery on the digestive system, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, chronic kidney disease, unspecified severe protein-calorie malnutrition, parkinsonism, dysphagia, restlessness and agitation, age related physical debility, abnormal weight loss. A review of the admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 11, 2024, revealed Resident 6's BIMS score was 99 (Brief Interview for Mental Status- a tool to assess cognitive function; a score of 99 indicates that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician order was followed related to unplanned weight loss for one of 19 residents with weight loss reviewed (Resident R6). Findings include: Clinical record review revealed that Resident R6 was admitted to the facility on [DATE], with the diagnosis of encounter for surgical after care following surgery on the digestive system, acute respiratory failure with hypoxia, unspecified severe protein-calorie malnutrition, dysphagia, age related physical debility, abnormal weight loss. A review of the admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 11, 2024, revealed Resident 6's BIMS score was 99 (Brief Interview for Mental Status- a tool to assess cognitive function; a score of 99 indicates that the resident was unable to provide or did not provide answers to complete this…

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

Based on observation, and interviews with staff, it was determined that the facility failed to maintain an environment free from hazards related to an unlocked medication cart and medication unsecured on the cart for one of two nursing units. Findings include: Observation of medication administration on April 4, 2024 at 9:15 a.m. revealed that the medication cart assigned to Employee E10, licensed nurse, was left on the second floor hallway unattended and unlocked. The cart was observed to have two medications left on top of the cart (Furosemide: a diuretic used to treat fluid retention and Ampicillin: an antibiotic used to treat bacterial infections). Further observation revealed Employee E10 exiting a resident's room and walking down the second floor hallway to the unattended and unlocked medication cart. This observation was confirmed by Employee E10 when she returned to the cart at 9:17 a.m. Continued observation of medication pass revealed Employee E10 preparing medication for Resident R23. Employee E10 pushed medications through several blister packs and turned the blister…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interviews, and clinical record review, it was determined that the facility failed to provide oxygen as ordered for two of 19 residents (Resident R43, R86). Findings include: Review of the clinical record revealed that Resident R43 was admitted to the facility on [DATE], with the following diagnosis chronic obstructive pulmonary disease with acute exacerbation, acute and chronic respiratory failure with hypercapnia (excessive carbon dioxide in the bloodstream, typically caused by inadequate respiration) and hypoxia (deficiency in the amount of oxygen reaching the tissues) Review of Resident R43's physician's order dated March 5, 2024, indicated to administer three liters of oxygen via nasal cannula continuously. During an observation on April 2, 2024, at 10:15 a.m. Resident R43 observed having oxygen level at 3.5 liter. Then on April 3, 2024, at 4, 2024 at 10:15 a.m. observation was made having oxygen level at 2.5 liter. During the second observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy and interview with staff, it was determined that the facility did not ensure that food was served in accordance with professional standards for food service safety for one of 19 residents reviewed (Resident R 47). Findings include: Review of facility policy, Reheating Resident Food and Beverages, revised June 2012, revealed Policy: to reduce the risk of Resident burns related to hot beverages, liquids and food, and to provide guidance on reheaing resident food and/or liquids. Staff members only are to reheat resident food and or liquids in the microwave to temperatures that are safe and palatable for residents. Procedure: 2. Items to be reheated are to be covered in the microwave. 4. Locate the dial thermometer available in the reheating area and wash with soap and running water to ensure thermometer is clean. 5. When item reheating is completed, staff member is to use a clean utensil to stir the item or liqid to ensure even heating throughout. The staff member is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents and interview with staff, it was determined that the facility failed to report a reportable incident via Event Reporting System to the local Department of Health DOH) for one of the 19 residents reviewed within the required and appropriate time frames. (Resident R83) Findings include: A review of a clinical record indicated that Resident R83 was admitted to the facility on [DATE], with the following diagnosis of anxiety disorder, dementia unspecified severity with other behavioral disturbance, major depressive disorder recurrent, severe with psychotic symptoms, adjustment disorder with depressed mood, disorientation. A further review of the progress notes dated, December 23, 2023, indicated resident visualized w/bed remote at neck, attempting to wrap cord around his neck. Verbalized he wanted to kill himself several times. Staff safety removed, cord, wires, and other self-harm items from within resident's reach .new order to send resident to nearest emergency room 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.