Kadima Rehabilitation & Nursing At Irwin

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medication and/or biologicals in one of two medication rooms (A Wing Medication Room). Finding include: Review of facility policy Storage of Medication dated 9/3/25, previously review 9/18/24, indicated medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. During an observation on 12/18/25, at approximately 9:00 a.m. of the A Wing medication room the following was observed- 16 boxes (10 syringes/each) Influenzae Vaccine 2024-2025 formula- Expired 6/30/25- 1 box ( 9 syringes Influenzae Vaccine 2024-2025 formula-Expired 6/30/25- 2 boxes-Gvoke HypoPen (glucagon Injection Pen)- Expired 6/2025- 4 boxes 50% Dextrose Injection-Expired 5/2025 During a review of all residents clinical record for administration of Influenzae vaccines, no residents were found to have received the expired medications. During an interview on 12/18/25, at 2:00 p.m. with the Nursing Home Administrator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual, clinical record, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set Assessments were accurate and fully completed for one of eight residents (Resident R1).Finding include:Review of the facility policy Resident Assessment/Minimum Data Set, dated [DATE], indicated the facility will conduct initially and periodically a comprehensive, accurate, and standardized reproducible assessment of each resident's functional capacity under the direction of a designated registered nurse.Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS-periodic assessment of care needs) dated October 2024, indicated that Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical and facility record review, facility submitted documents and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent a fall and an elopement for two of eight residents (Resident R1 and Resident R2). Finding include:Review of facility policy, Transfer of Residents dated 9/18/24, indicated residents will be evaluated, supervised, or assisted to ensure the appropriate method of transferring a resident is identified to minimize emotional and physical trauma to the resident.Review of facility policy, Resident Elopement dated 9/18/24, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the premises or a safe area without authorization.Review of facility policy, Elopement Drill dated 9/18/24, indicated elopement drills will be held to prepare staff to search for a resident who is missing or has eloped.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 review of facility policies, clinical procedures and staff interviews, it was determined that the facility failed to make certain medical records on each resident are complete and accurately documented for one of eight residents. (Resident R1).Findings include:A review of the facility policy Documentation dated 9/18/24, indicated nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate. Narrative charting, as outlined in specific policies and procedures, will be used for initial treatments or procedures. Documentation for subsequent and/or routine care and procedures may be completed by exception, or the use of a checklist, flowcharts, or other documentation tools. Nursing documentation will provide accurate reflection of resident condition and will meet federal and state requirements.A review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included aphasia (a language disorder that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to protect residents from neglect for one of five residents (Resident R1). Based on review of facility policy, published documents, clinical record review and staff interviews, it was determined that the facility the facility failed to protect residents from neglect for one of five residents (Resident R1). This was identified as past non-compliance. Findings include: Review of the facility policy, Abuse Protection, defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary. Review of the American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated the patient should always roll toward you not away from you. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls for one of five residents (Resident R1).Based on review of published documents, clinical record review, facility provided documents and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls for one of five residents (Resident R1). This was identified as past non-compliance.Findings include:Review of the American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated the patient should always roll toward you not away from you.Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 5/6/25, included diagnoses of muscle weakness, debility, and dementia (a group of symptoms that affects memory, thinking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility job descriptions, personnel files, and staff interviews, it was determined the facility failed to ensure that staff renewed their nurse aide registration to allow individuals to work as a nurse aide for one of five nurse aides (NA) reviewed (NA Employee E1). Based on review of facility provided documentation, it was determined that the facility failed to have updated certifications on file for one of five Nurse Aides (NA), which allowed NA Employee E1 to work without a current certification.Review of the facility documents provided indicated that nurse aides, Must possess an active Certified Nursing Assistant Certification; having successfully completed a State approved training program and necessary examination.Review of facility submitted information dated [DATE], indicated, As part of a routine internal audit, conducted to ensure compliance with licensure requirements, it was identified that employee's [Nurse Aide Employee E1] license had expired as of [DATE]. Upon identification…

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

Based on a review of facility policies and documents, and staff interviews, it was determined that the facility failed to properly monitor equipment in the Main Kitchen creating the potential for food-borne illness. Findings include: A review of facility policies Equipment Temperature Logs dated 9/18/24, indicated that the Dietary Services Manager will use the Refrigeration and Freezer Temperature Log to record the temperatures of all refrigerators and freezers daily. The forms will be posted in the Dining Services Department and kept on file for a period of one year. A review of the Equipment Temperature Log, To Be Taken daily by the Dietary Services Manager documents dated 12/1/24 through 1/27/25 did not include documentation that temperatures were taken on the following days for the walk in and reach in coolers and freezers, and milk cooler: 1/6/25. 1/13/25. 1/16/25. 1/18/25. During an interview on 1/27/25, at 9:50 a.m., the Nursing Home Administrator and Dietary Services Manager E1 confirmed the above findings, and that the facility failed to monitor equipment temperatures…

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

Based on observations and interview, the facility failed to store medications in a safe and sanitary manner for one of three medication carts reviewed (A unit Long Hall, and B unit Short Hall). Findings: Review of facility policy Infection Control Plan, Program, and Committee reviewed 9/18/24, indicated the facility maintains a structured Infection Control Program focused on prevention and management of infections. During an observation on 1/28/25, at 9:10 a.m., A unit Short Hall medication cart contained six of six insulin pens in compartments unbagged, posing the risk of cross-contamination. During an interview at that time, Licensed Practical Nurse (LPN) Employee E3 confirmed the insulin pens were unbagged. During an interview on 1/28/25 at 10:00 a.m. the Director of Nursing confirmed the facility failed to prevent the risk of cross-contamination by storing insulin pens unbagged in the medication carts for A unit Long Hall medication carts. 28 Pa code 201.14(a) Responsibility of licensee 28 Pa code 211.12(d)(1) Nursing services

Based on a review of facility policy, federal regulation, and staff interview, it was determined that the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for 4 of 12 months (January 2024 through April 2024). Findings include: Review of the facility policy admission Transfer and Discharge 9/21/23 and 9/18/24, indicated no resident will be discharged without timely notification of the resident, responsible party, or authorized representative. Review of Title 42 Code of Federal Regulations §483.15(c)(3) Notice Before Transfer: indicates, before a facility transfers or discharges a resident, the facility must (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Federal Regulations further define emergency transfers as, When a resident is temporarily transferred on an emergency basis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a significant change Minimum Data Set (MDS- assessments completed indicating a change in condition of a resident requiring change in care) assessment for one of three residents reviewed (Residents R97). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual (reference used to complete an MDS) effective 10/1/2019, indicated that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. Review of the facility policy Resident Assessment/Minimum Data Set reviewed 9/18/24, indicated the facility will conduct a comprehensive assessment of a resident in a timely manner, within 14 days after the facility determines that there has been a significant change. The change is a decline or improvement in a resident's status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels for two of four residents reviewed (Residents R51 and R66). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interviews, it was determined that facility staff failed to maintain ongoing communication with the dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of four residents reviewed (Resident R2). Findings include: Review of the facility policy Dialysis Care reviewed 9/18/24, indicated residents ordered dialysis will be monitored and documentation will be maintained in the medical record. All resident ' s receiving dialysis will be assessed before and after dialysis treatment and for compliance with their individualized plan of care. Review of the clinical record indicated Resident R2 was re-admitted to the facility on [DATE], with diagnoses that included end-stage renal disease (ESRD - the kidneys permanently fail to work), high blood pressure, and depression. Review of the Minimum Data Set (MDS - periodic assessment of care needs) date 1/15/25, indicated 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 review of facility policy, observations, and staff interviews it was determined that the facility failed to properly store refrigerated medication in one of three medication carts observed (B unit Short Hall medication cart). Findings include: Review of facility policy Storage of Medications reviewed 9/18/24, indicated medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. Medications requiring refrigeration must be stored in the refrigerator located in the drug room at the nurses station. Review of Humalog (Lispro) Instructions for Use guidelines revised July 2023, indicate unused pens should be stored in the refrigerator at 36 - 46 degrees Farenheit. Unused pens may be used until the expiration date printed on the label, IF the pen has been kept in the refrigerator. Review of Highlights of Prescribing Information insert for Lantus insulin revised June 2023, indicate 10 ml (milliliter) multi-dose vial and 3 ml single-patient prefilled pen are good for 28 days if unopened at room temperature.…

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

Based on a review of facility policies and documents, and staff interviews, it was determined that the facility failed to properly monitor food temperatures in the Main Kitchen creating the potential for food-borne illness. Findings include: A review of facility policies Dietary Services Administration and Food Temperature Recording, dated 9/18/24, indicated that the facility provides food that is the proper temperature. Food temperatures will be taken and recorded by dining service staff prior to the start of each meal. All hot foods will be held and served above 135 degrees Farenheit. Food temperature logs will be kept on file. A review of the Daily Temperature Log, To Be Taken By [NAME] On Duty documents dated 12/7/24 through 1/7/25 did not include documentation that temperatures were taken prior to the start of the meal on the following days: 12/24/24, evening meal. 12/29/24, evening meal. 12/30/24, evening meal. 1/1/25, evening meal. 1/3/25, lunch meal. During an interview on 1/7/25, at 12:30 p.m., the Nursing Home Administrator and Registered Dietician Employee E1 confirmed…

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

Based on staff interviews and review of the Food Service Director's Job description, it was determined that the facility failed to employ a full-time qualified Food Service Director for six of six weeks (6/18/24 - 7/30/24). Finding include: Review of the facility's Food Service Director's Job Description indicated that the Food Service Director: · Must be a graduate of an accredited course in dietetic training approved by the American Dietetic Association. · Must be registered as a Food Service Director in Pennsylvania. · Must provide documentation of registry/certificate upon application for the position. During an interview on 7/30/24, at approximately 12:30 p.m. Food Service Director (FSD) Employee E1, stated that while she is currently enrolled in classes to be a Certified Dietary Manager (CDM), she currently is not certified. During an interview on 7/30/24, at 1:55 p.m. Registered Dietician Employee E2 stated that she works only one day per week, will be leaving the facility in two weeks, and further stated that she does not take any part in the operation and/or management 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 review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to make certain that weight loss was identified and addressed and identify needs for increased nutrition for eight of eleven residents (Resident R1, R2, R3, R4, R5, R6, R7, and R8). Findings include: Review of the facility job description for the Registered Dietitian indicated the primary purpose of the job position is to implement, coordinate, and evaluate the medication nutrition therapy for the residents, provide resident and family education, provide nutritional assessment and consultation to assist in planning, organizing, and directing the food and nutritional services of the facility. Included in the list of duties and responsibilities were: assist in developing a written dietary plan of care and to review nurse's notes to determine if the care plan is being followed. Review of the facility policy, Weight Monitoring and Weight Loss Intervention last reviewed 11/30/23, indicated '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.

Based on a review of facility policy, resident observations and interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 11 of 18 residents (Resident R5, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17). Findings include: Review of the facility policy, Nursing Department Staffing dated 11/30/23, indicated The facility will provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: -Licensed nurses -Other nursing personnel During an observation on 7/30/24, at 2:12 p.m., Resident R9, when asked if there was sufficient nursing staff stated, Some days yes. Sometimes they have three, and that's not enough. Resident R9 confirmed that he has been left in bed in urine soiled clothing and linen for an extended period of time. During an interview on 7/30/24, at 2:13 p.m., 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 documents, staff interviews, and the results of the previous and current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to implement a good faith attempt to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively six of six weeks (6/18/24 - 7/30/24). Findings include: Review of the facility's Food Service Director's Job Description indicated that the Food Service Director: · Must be a graduate of an accredited course in dietetic training approved by the American Dietetic Association. · Must be registered as a Food Service Director in Pennsylvania. · Must provide documentation of registry/certificate upon application for the position. During an interview on 7/30/24, at approximately 12:30 p.m. Food Service Director (FSD) Employee E1, stated that while she is currently enrolled in classes to be a Certified Dietary Manager (CDM), she currently is not certified. Review of the facility survey ending 6/18/24, included a citation 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 staff interviews, and review of the Food Service Director's Job description, it was determined that the facility failed to employ a full-time qualified Food Service Director for two of two months (April, May 2024 to current June 18, 2024). Finding include: Review of the facility's Food Service Director's Job Description indicated that the Food Service Director: · Must be a graduate of an accredited course in dietetic training approved by the American Dietetic Association. · Must be registered as a Food Service Director in Pennsylvania. · Must provide documentation of registry/certificate upon application for the position. During an interview on 6/18/2024 at 11:15 a.m. Food Service Director (FSD) Employee E1, stated that she was not a Certified Dietary Manager (CDM) and did not have any formal education or certificates in food service management. FSD Employee E1 stated that she has been a dietary aide in the facility but was promoted to FSD about two months ago. FSD Employee E1 also clarified that she is not currently enrolled in any classes to become a CDM. During an…

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

Based on a review of facility policy, resident observations and interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 13 of 16 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, and R13). Findings include: Review of the facility policy, Nursing Department Staffing dated 11/30/23, indicated The facility will provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: -Licensed nurses -Other nursing personnel During an observation on 2/25/24, at 1:15 p.m., Resident R1 was noted to have long, greasy-appearing hair, that was not brushed. During an observation on 2/25/24, at 1:16 p.m., Resident R2 was noted to be wheeling around the dining room, with bare feet. During an observation on 2/25/24, at 1:22 p.m., Resident R3's room smelled of urine. Upon entering…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility polices, documentation, review of Pennsylvania Department of Health (PADOH) guidelines for Group A Streptococcus (GAS, bacteria commonly found in the throat and on the skin that can cause a variety of infections) infections, Centers for Disease Control (CDC) recommendations, and staff interviews, it was that the facility failed to respond to GAS infections in the facility for twelve of 15 residents (Resident R6, R11, R13, R14, R15, R16, R17, R18, R19, R20, R21, and R22). Review of the PADOH document Overview for Long-Term Care Facilities: Invasive Group A Streptococcus (invasive GAS is an infection of group A strep in an area of the body generally considered sterile, such as blood, bone, spinal fluid, and internal body sites) updated August 2022, indicated: Group A Streptococcus (GAS) is a type of bacteria that can cause infection. It's also known as Streptococcus pyogenes. These bacteria can infect people in different ways: -Common and non-invasive: strep throat, body rash, sores…

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

Based on a review of the facilities four week cycle menu, observations, and resident and staff interviews it was determined that the facility failed to provide food products as listed on the menu for eight of eight residents on 12/27/23. (Resident R5, R6,R7, Resident R8, R9, R10, R11, R12 ). Findings include: A review of facility's Menus policy dated 11/30/23, indicated standardized seasonal cycle menus are prepared and will fulfill the residents' nutritional and therapeutic needs. It stated the facility Dietician and Dining Services Manager will review the menus and make suggestions for revisions. Suggestions for menu revisions should be based upon input from the facility Resident Council and Facility Dining Committee. No major change in the standardized menu is to be made without approval by the Corporate Menu Team. A review of the facility's Facility Diets policy dated 11/30/23, indicated facility diets will be available at all meals. All physician orders must conform to the diet title as indicated in this descriptions. Any diet not complying must be clarified via discussion with…

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

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to properly restrain facial hair and failed prevent cross contamination on the tray line in the Main Kitchen. Findings include: Review of the facility policy Personnel Standards reviewed 11/30/23, indicated dining services personnel shall follow sanitary standards. Hair nets or caps, covering all of the hair, must be worn at all times while on duty. Hands must be washed after each trip to the restroom, after leaving storage rooms, dumpster areas, and at any other time it is necessary. During the tray line on 12/17/23, between 11:40 a.m. and 12:15 p.m. the following was observed: -11:43 a.m. Dietary Aide Employee E6 and [NAME] Employee E7 donned gloves without washing their hands to start tray line. -11:50 a.m. [NAME] Employee E9 donned gloves without washing her hands. -11:56 a.m. [NAME] Employee E9 removed the coverings/wrapping off prepared food, removed a lid from the shelf and returned to removing food covers. No handwashing or glove change observed. -11:59 a.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and resident interviews, it was determined that the facility failed to provide in a manner that enhanced resident dignity during dining services for two of 11 residents (Resident R14 and R66). Findings include: Review of the facility policy Dining Experience last reviewed on 11/30/23, with a previous review date of 11/3/22, indicated that the dining experience will be safe and satisfying for each resident. Residents are assisted in a dignified and timely manner. During an observation on 12/18/23, from 12:00 p.m., through 12:45 p.m., Resident R14 was seated at a table with three other residents who had been served their trays at 12:20 p.m., Resident R14 did not receive his tray until 12:27 p.m. During an interview on 12/18/23, at 12:22 p.m., Resident R14 stated that he was hungry and yelled out where's the food. During an observation on 12/18/23 from 12:00 p.m. through 12:45 p.m., Resident R66 was seated at a table with 6 other residents who had received their trays by 12:26 p.m., Resident R66 did not receive her tray until 12:45 p.m., after others had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy and clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for six of the nine residents reviewed (Resident R4, R25, R39, R58, R63, R301). Findings Include: A review of the facility policy Advanced Directives last reviewed 11/30/2023, indicated the facility will comply with requirements relating to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. A review of the medical record indicated Resident R4 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, bi-polar (severe 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.

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to maintain a clean, homelike environment on three of three nursing units (A Wing, B Wing and C Wing) and in two of two shower rooms and outside of the facility near to back of the building at A wing back entrance and failed to provide a homelike environment for one of five residents (Resident R91) Findings include: Review of the facility policy Environmental Services, Clean, Safe and Orderly Environment last reviewed on 11/30/23, indicated that the interior and exterior of the facility will be maintained in a clean, safe and orderly manner and provide a homelike environment shall be one that de-emphasizes the institutional character of the setting. During an observation on 12/19/23, at 8:45 a.m., Shower room of the A wing had the following items: The entrance was blocked with two, two-bin care carts. the room had two bariatric shower chairs and one regular sized shower chair that were soiled with unknown substances, two hoyer lifts and one Sara lift leaving the shower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records, grievance forms and staff interview, it was determined that the facility failed to ensure that three of four residents (Residents R10, R16 and R38) were free from abuse by not identifying allegations of neglect as potential abuse and allowing staff to continue to care for residents. Findings include: Review of the facility policy Abuse protection, last reviewed on 11/30/23, with previous review date of 11/1/23, indicated that residents have a right to be free from abuse. All reports of abuse are investigated timely and thoroughly and the residents are protected from abuse during the investigation. Review of the clinical record indicated that Resident R10 was admitted to the facility on [DATE], with diagnoses of heart failure, diabetes, obesity and difficulty walking. Resident R10 had a readmission date of 10/26/23, with additional diagnosis of kidney failure. A Minimum Data Set (MDS - periodic assessment of resident care needs) dated 11/1/23, indicated 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 policies, clinical records, grievance forms and staff interview, it was determined that the facility failed to ensure that three of four residents (Residents R10, R16 and R38) allegations of abuse/neglect were thoroughly investigated and/or reported to the State Agencies as required. Findings include: Review of the facility policy Abuse Reporting and Investigation, last reviewed on 11/30/23, with previous review date of 11/1/23, indicated that the facility will thoroughly investigate all reports of suspected or alleged abuse and injuries of unknown origin and the facility will ensure prompt enforcement of employee disciplinary procedures in the case of alleged or suspected abuse/neglect. The State will be notified of the alleged events as well as all other authorities. Review of the clinical record indicated that Resident R10 was admitted to the facility on [DATE], with diagnoses of heart failure, diabetes, obesity and difficulty walking. Resident R10 had a readmission date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for two of eight residents (Resident R32 and Resident R54). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated the following instructions: -Section I - Active Diagnoses, indicated that an active diagnosis is a physician-documented diagnosis in the previous 60 days that have a direction relationship to the resident's current functional status, cognitive status, mood or behavior. -Section J - Health Conditions: Current Tobacco Use, Ask the resident if they used tobacco in any form during the 7-day look-back period. If the resident states that they used tobacco in some form during the 7-day look-back…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for three of eight residents (Residents R18, R54, and R90). Findings include: Review of facility policy MDS/RAI/Care Planning last reviewed on 11/30/23, with a previous review date of 11/3/22, indicated: Develop a written plan of care individualized for each resident, which identifies through an assessment process his/her strengths, problems and needs. Review of Resident R18's admission record indicated he was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels) and urine retention (difficulty urinating or completely emptying the bladder). Section H: Bladder and Bowel indicated the presence of an indwelling catheter (a flexible tube inserted into the bladder to drain it, which remains in place). Review of physicians'…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for seven of ten Residents (Residents R4, R10, R23, R25, R34, R47, and R54). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility policy, review of grievances,observation, and resident and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties in the Main Kitchen. Findings include: The facility Mealtimes and Delivery policy dated 11/30/23, indicated that meals are provided at scheduled meal times to assure that each resident receives three meals per day. Trays are delivered sequentially and timely. Review of the Scheduled meal times posted indicated the following delivery times and locations: Lunch is to be delivered to the the Dining Room at 12:00 noon. 1st cart- A wing rooms 45-56 trays delivered 12:10 p.m. 2nd cart- B wing rooms 13-28 at 12:20 p.m. 3rd cart- A wing rooms 29-43 at 12:35 p.m. 4th cart- B wing rooms 1-12&61-66 at 12:45 p.m. Review of a grievance dated 7/6/23, indicated that meals are not served on time and staff using cell phones while delivering trays. Review of a grievance dated 7/24/23, indicated that a resident did not receive meal trays over weekend and had to use call bell to ask for his food.…

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

Based on a review of facility policy, resident interviews, Resident Group meeting, observation, and staff interviews, it was determined that the facility failed to provide the residents with a palatable meal, and at an appetizing temperature for one of one lunch meal observed. (Lunch Meal on 12/18/23). Findings include: Review of the facility policy The facility Mealtimes and Delivery policy dated 11/30/23, indicated that meals are provided at scheduled meal times to assure that each resident receives three meals per day. Trays are delivered sequentially and timely. During an interview on 12/18/23, at 10:40 a.m., Resident R10 stated that the food is always cold, the buns are placed on he plate with liquid from the vegetables and so they get wet and we get plastic silverware. During an interview on 12/18/23, at 10:42 a.m., Resident R84 stated that food is always cold and buns are wet, can't get coffee in the morning with no cups. During an interview on 12/18/23, at 10:43 a.m., Resident R50 agreed with Resident R84 and stated they do not get regular silverware, only plastic, how can…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review and resident and staff interviews, it was determined that the facility failed to provide a nutritious snack before or at bedtime for three of three nursing units (A wing, B wing and C wing nursing units). Findings include: Review of the facility policy Snacks, last reviewed on 11/30/23, indicated that residents will receive snacks for supplemental or between meal nourishment. During the Resident Group meeting on 12/18/23, from 2:30 p.m., to 4:00 p.m., the group consensus indicated that bedtime snacks are not provided. The refrigerator is suppose to have snacks for residents to get and staff should be bringing snacks around to those who cannot get out of bed, however, the refrigerator contained peanut butter and jelly sandwiches. No other snacks were available for residents of the facility. During an interview on 12/19/23, at 9:30 a.m., the Nursing Home Administrator confirmed that the facility failed to provide a nutritious snack for between meals and at bedtime. 29 Pa. Code: 211.6(a)Dietary services.

Based on review of the facility's admission agreement and staff interviews, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator. Findings include: Review of facility's admission Agreement packet, which contained the document Voluntary Arbitration Agreement indicated that Accordingly, any dispute arising out of relating to the provision of services by the Facility to the Resident, Resident's admission to the Facility, Resident's contracts with the Facility or the subject matter thereof, any breach of contract, including any dispute regarding the execution, validity or scope of this Arbitration Agreement or any of its clauses, will be resolved through arbitration administered by [name of arbitrator services company which the facility utilizes] and conducted pursuant to the [arbitrator] Rules of Procedure for Arbitration. The facility's arbitration agreement failed to provide for the selection of a neutral arbitrator agreed…

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

Based on a review of facility documents, personnel records, and staff interview, it was determined that the facility failed to employ a qualified social worker for one of two employees (Employee E3). Findings include: Review of the facility policy Social Services Administration dated 11/30/23, with a previous review date of 11/3/22, included the following: A qualified social worker is defined as an individual who meets, at a minimum, one of the following qualifications: 1. A bachelor's degree in social work, or 2. A bachelor's degree in human services field. 3. A bachelor's degree in social work or a bachelor's degree in a human services field including but not limited to sociology, special education, rehabilitation and counseling, and psychology. 4. One year of supervised social work experience in a health setting working directly with individuals. Review of the facility provided job description for the Social Services Director included the educational requirement of a bachelor's degree in social work or a related field. Review of the personnel record for Social Services Director…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility documents, observations, clinical record review, and staff interview, it was determined that the facility failed to ensure residents receive culturally sensitive care to maintain the highest level of psychosocial wellbeing for one of two non-English speaking residents (Resident R68). Findings include: Review of the Facility Assessment updated 10/31/23, indicated the facility works together to identify the individual cultural and religious factors. Review of Resident R68's admission record indicated she was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS- periodic assessment of resident care needs) dated 11/2/23, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and osteoarthritis (degeneration of the joint causing pain and stiffness). Section A: Identification Information indicated Resident R68's preferred language is English, and that she does not require an interpreter to communicate 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.

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to properly secure medication in a medication cart in one of six medication carts (A Long Hall). Findings include: Review of the facility policy Storage of Medications reviewed 11/30/23, indicated medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. Medications are stored in an orderly manner in cabinets, drawers, or carts. During an observation on 12/20/23, at 11:18 a.m. A Long Hall medication cart was placed outside of resident rooms with medications left unattended on top of the medication cart. Medications left unattended included: -open bottle of lactulose -open bottle of Vitamin B12 -insulin pen -multiple empty blister medication packs with identifying information During an interview on 12/20/23, at 11:21 a.m. the Assistant Director of Nursing Employee E4 confirmed the medications should not be left on top of the medication cart and accessible to residents. During an interview 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.

Based on observations and staff interview, it was determined that the facility failed to properly label food products in the dry storage and freezer area and maintain sanitary conditions in the dish room which created the potential for cross contamination in the designated main kitchen. Findings include: During an observation of the main designated kitchen on 11/29/23, at 9:45 a.m. the following was observed: - 1 bags of cheerios- no label - 2 bag of rice krispies- no label - 1 bag of corn flakes-no label - 1 bag of chicken patties-no label or date During an observation of the main designated kitchen on 11/29/23, at 10:00 a.m. the following was observed: (2) Wall fan's above clean side of dishwasher, brown debris During an interview on 11/29/23 at 10:15 a.m., Dietary Manager Employee E1 confirmed that the facility failed to properly label and date food products and maintain sanitary conditions which created the potential for food borne illness. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.6(c) Dietary services. 28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on federal code and staff interview it was determined that the facility failed to have a qualified activites professional. Findings include: Review of the United States Code of Federal Regulations(CFR), 483.24(c) indicated the activites program must be directed by a qualified professional. During an interview on 11/29/23, at 11:30 a.m., the Nursing Home Administrator confirmed that the facility's Activity Director failed to have the qualifications necessary to oversee the activites program 28 Pa. Code: 201.18(b)(3)Management

Based on a review of facility policy, observation and staff interview, it was determined the facility failed to store a hydration item in accordance with professional standards for food service safety in one of three ice machine areas (Unit A). Findings include: Review of facility policy titled Food Storage last reviewed 11/1/22, informed frozen foods will be stored at 0 degrees Fahrenheit or below at all times. All packaged food, canned items or food items stored will be kept clean and dry at all times. All foods stored in walk- in refridgerators and freezers shall be stored above the floor on shelves, racks, dollies, or other surfaces that facilitate a thorough cleaning. During an observation on 8/22/23, at 10:40 a.m. four, seven pound bags of ice were stored on the floor in front of the ice machine in the supply closet on Unit A. During an interview on 8/22/23, at 10:40 a.m. Dietary Aide Employee E2 confirmed the facility failed to store the ice in accordance with professional standards for food service safety. 28 Pa. Code 211.6(f) Dietary services. 28 Pa. Code 207.4 Ice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interviews, resident interviews, and grievance reviews it was determined the facility failed to maintain mechanical equipment in a safe operating condition for one of three ice machines (Unit B). Findings include: During an observation on 8/22/23, at 10:42 a.m. the ice machine on Unit B was found to be inoperable. The machine was plugged in, did not have any ice, and was room temperature to the touch. During an interview on 8/22/23, at 10:42 a.m. Dietary Aide Employee E2 confirmed the ice machine on Unit B was inoperable. During an observation on 8/22/23, at 10:42 a.m. three, seven pound bags of ice were in a cooler on Unit B. During an interview on 8/22/23, at 10:45 a.m. Resident R2 reported 'the ice machine has been broken for 2 weeks. The kitchen has ice, but everyone uses it and it runs out. It sucks, i like ice water.' During an interview on 8/22/23, at 2:15 p.m. Resident R5 reported hydration cups are 'not filled with water or ice. The ice machine has been broken off and on.' Review of a grievance concern dated 8/9/23, by Resident R7 and Resident R8…

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