Willows Of Presbyterian Senior

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to obtain a physician order for a wound vac for one of one resident (Resident R189).Findings include: A review of the clinical record indicated Resident R189 was admitted to the facility on [DATE], with diagnoses that included infection and inflammatory reaction due to internal right knee prosthesis, bacteremia (presence of bacteria in the bloodstream) and congestive heart failure (heart can ' t pump blood well enough to give your body a normal supply).A review of Resident R189's admission MDS (minimum data assessment) assessment- (periodic assessment of resident care needs) dated 9/29/25, indicated the diagnosis remained current. During an interview with Resident R189 on 9/29/25 at 10:30 a.m., R189 had a wound vac attached to the left hand side of her wheel chair. R189 stated it was for her knee. A review of Resident R189's physician orders dated 9/24/25 indicated no order for the wound vac.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive resident-specific plan of care for a resident with limited mobility requiring equipment and assistance to maintain or improve mobility for one of three residents (Resident R6).Findings include:Review of facility policy Splinting dated August 2025, indicated there must be a physician's order for splinting. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE].Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/22/25, indicated diagnoses of gastroesophageal reflux disease (GERD - when stomach acid flows back into the esophagus, causing symptoms like heartburn), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and hemiplegia (paralysis on one side of the body). During an observation on 9/29/25, at 12:11 p.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripheral inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) in accordance with professional standards of practice for one of two residents (Resident R17).Findings include:Review of Resident R17's admission record indicated the resident was admitted to the facility on [DATE].Review of Resident R17's Minimum Data Set (MDS - periodic assessment of care needs) dated 8/29/25, included diagnoses of depression, cancer (a disease characterized by abnormal cell growth and division), and low back pain. During an observation on 9/29/25, at 9:24 a.m. Resident R17 was lying in her bed and a double lumen PICC line was observed in right upper arm. Resident R17 stated it was used for getting fluids once a week and for her chemotherapy medication.During a review of physician…

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 interviews, it was determined the facility failed to dispose of or reconcile discontinued medication in a timely manner for one of two medication rooms reviewed (Fourth Floor Medication Room).Findings:Review of facility Medication Disposal-Non-controlled Medications policy dated August 2025, indicated discontinued medications and medications left in the facility after a resident ' s discharge or death should be disposed of in a timely manner. Any non-controlled medication product that is discontinued should be appropriately documented on a Medication Reconciliation form.During a medication room review on 9/30/25, at 10:18 a.m. a plastic bin over filled with medication was observed sitting in the corner of the medication room, unsecured and unaccounted for. The medications observed were:- Tylenol (used for fever or pain) - 28 pills- Lovenox injections (used to prevent blood clots) - Two injections- Omeprazole (used to treat acid reflux) - Three pills- Gas Relief - Two bottle- Immodium (used to treat diarrhea) - 30 pills-…

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, and staff interview, it was determined that the facility failed to properly store medical supplies in one of two medication rooms (Fourth Floor Medication Room), and failed to properly secure a medication cart while not in use for one of nine medication carts (Third Floor West/Northwest Medication Cart).Findings include:Review of facility policy Skilled Nursing - Medication Storage dated [DATE], indicated during a medication pass, medications must be under the direct observation of the person administering the medications or locked in the medication storage area/cart. All drugs and biologicals will be stored in locked compartments under proper temperature controls. Facility will ensure all medications housed on our premises will be stored in medication rooms according to recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. During a medication storage room review on [DATE], at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to make certain exit seeking/wandering residents had a person-centered care plan individualized to each specific resident's needs for eight of 35 residents identified as high risk for wandering/elopement (Residents R1, R2, R3, R4, R5, R6, R7, and R8). Findings included: Review of the facility policy Skilled Nursing-Comprehensive Care Plans dated August 2024, indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. Review of the facility Elopement Process dated August 2024, indicated an elopement device should be placed if the resident scores a one or above on the elopement evaluation and are an elopement risk. Review of…

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

Based on a review of facility policies, documents and staff interviews it was determined that the facility failed to report to the State agency an allegation of misappropriation of resident property as required. (Allegation of misappropriation of resident property). Findings include: A review of facility Skilled Nursing - Abuse policy dated 8/24, revealed that the purpose of the policy is to comply with the seven step approach to abuse and neglect detection and prevention. Abuse is defined to include misappropriation of resident property. Step seven of the approach includes reporting the allegation to the proper agencies. During a review of facility documents submitted to the state agency it was revealed that the facility failed to notify the state agency of allegations of facility staff improperly destroying medications no longer prescribed for the resident as required. During a staff interview on 5/21/25 at 9:00 am the Nursing Home Administrator and Director of Nursing revealed that they were aware of allegations of staff members inappropriately destroying resident medications.…

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 and staff interviews it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for eight of 12 residents (Resident R3, R5, R70, R73, R76, R93, R113, and R361). Findings include: Review of the facility policy Resident Rights - Quality of Life - Homelike Environment dated August 2024, indicated the facility will provide residents with a safe, clean, comfortable, and homelike environment. Review of Title 42 Code of Federal Regulations §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Review of the admission record indicated Resident R3 was admitted to the facility on [DATE]. Observation on 11/18/24, at 10:30 a.m. of Resident R3's room indicated gouges in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and interview, the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice for four of four residents (Residents R12, R24, R44, and R60). Findings include: Review of facility policy Skilled Nursing-Oxygen Administration dated August 2024, indicated oxygen is administered residents who need it, consistent with professional standards of practice and the care plan. Oxygen is administered under orders of a physician unless in emergency an order can be obtained as soon as the situation is under control. Review of facility policy Skilled Nursing--Cleaning Changing Nasal Cannulas and Masks dated August 2024, indicated all residents who are receiving oxygen therapy shall have masks and nasal cannula tubing changed weekly and/or as needed. Review of admission record indicated Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic…

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, resident and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of nine residents (Resident R46). Findings include: Review of facility policy Nursing-Medication and treatment orders dated 8/24 indicated medications shall be administered only upon written order of duly Licenced and authorized to prescribe such medications in this state. Review of the admission record indicated Resident R46 was admitted to the facility on [DATE], with diagnosis that include morbid obesity, congestive heart failure (serious condition that occurs when the heart can't pump enough blood to meet the body's needs) and diabetes mellitus. Observation on 11/18/24, at 10:15 a.m. Resident R46 was laying in bed, on bed side table there was a cup with 4 pills. Resident R46 stated she had dropped a pill and didn't know where it was located. During and interview on 11/18/24, at 10:45 a.m. Registered Nurse (RN) Employee E4 confirmed Resident R46 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 the Resident Assessment Instrument (RAI) Users Manual, clinical record review, and staff interview, it was determined that the facility failed to timely complete a quarterly Minimum Data Set (MDS) assessment for one of nine residents. (Resident 144) Findings include: The Long-Term Care Facility RAI User's Manual, which provides instructions and guidelines for completing required MDS assessments (mandated assessments of a resident's abilities and care needs), revised October 2023, indicates that quarterly assessments must be no more than 92 days after the Assessment Reference Date (ARD) of the most recent assessment, and the assessment was to have a completion date that was no later than the ARD plus 14 calendar days. Clinical record review revealed that Resident 144 had an admission MDS assessment completed on 6/6/24. There was no evidence that any MDS assessment, including a quarterly assessment, had been completed after 6/6/24. Review of Resident R144's clinical record on 11/21/24, indicated a quarterly MDS assessment was to be completed by 9/20/24. It was 62…

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 two residents (Resident R36 and R158). 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: -Observation (Look-Back, Assessment) Period is the time period over which the resident's condition or status is captured by the MDS assessment. Most MDS items themselves require an observation period, such as 7 or 14 days, depending on the item. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the observation period must also cover this time period. A standard 7-day look-back period counts back from and includes the Assessment Reference Date (ARD+6 previous days).…

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 facility policy, clinical records and staff interview, it was determined that the facility failed to update a care plan for one of two residents (Resident R316) to accurately reflect the current status of the resident. Findings include: Review of facility policy Comprehensive Care Plan dated 8/24 indicates a comprehensive person centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and physiological needs is developed for each resident. Review of clinical record indicated Resident R316 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (serious condition that occurs when the heart can't pump enough blood to meet the body's needs), asthma and atrial fibrillation a heart condition that causes an irregular and often rapid heartbeat in the upper chambers of the heart). Review of Resident R316's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated…

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 resident's interview, clinical record review and review of the facility policy, it was determined that the facility failed to provide the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including communication (Resident R36), and eating (Resident R60) for two of seven residents. Finding include: Review of the facility policy titled, Nutritional Assessment and Care Plan last reviewed 8/24, indicated the Dietician will complete a comprehensive nutritional assessment and nutritional care plan for each resident to be individualized to that resident's nutritional problems and/or needs. The information will be documented in the resident's clinical record. Review of Resident R36's admission record indicated she was admitted to the facility on [DATE], with diagnoses of aphasia (a disorder that results from damage to portions of the brain that are responsible for language) and dysphagia (difficulty swallowing). Review of Resident R36's…

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, observations, and staff interviews, it was determined that the facility failed to ensure vital signs parameters (value ranges) were documented on the medication administration record per physician orders for two of six residents (Resident R24, and R70), and failed to discontinue incisional care once healed for one of six residents (Resident R151). Findings include: Review of facility policy Nursing Documentation of Medication Administration dated August 2024, indicated the facility shall maintain a medication administration record to document all medications administered. Review of the facility policy Nursing - Medication and Treatment Orders dated August 2024, indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. Review of the admission record indicated Resident R24 admitted to the facility on [DATE]. Review of Resident R24's Minimum Data Set (MDS - a periodic assessment of care needs)…

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, clinical records, facility documents and staff interviews, it was determined that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three residents (Resident R72). Findings include: Review of facility policy Stage and Treat Pressure Injury, updated in August 2024, indicated the following: 1. Cleanse wound with normal saline before identification and measurement, unless contraindicated. 2. Describe appearance (redness, rash, puffiness, observe edges of wound). 3. Measure length, width, and depth of wound with disposable tape measure. 4. Inspect for drainage and odor. 5. Inspect for presence of eschar in wound bed. 6. Inspect for tunneling. 7. Use Staging Document in Reference options, to identify stage of wound 8. Initiate treatment identified in the Staging Document for the identified stage. Review of facility policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician-ordered contracture management interventions were provided as care planned for one of four residents reviewed (Resident R60). Findings include: Review of Resident R60's admission record indicated she was admitted to the facility on [DATE], readmitted [DATE], with diagnoses of dysphagia (difficulty swallowing), depression, and hemiplegia (paralysis affecting one side of the body). Review of Resident R60's MDS assessment dated [DATE], indicated the diagnoses were current. Review of Resident R60's [NAME] (care plan chart or template used by nurses to summarize important information about a patient's needs on 11/19/24, indicated the resident will wear palm guard daily on in the morning and off at dinner time. During an observation and interview on 11/20/24, Resident R60 was observed without a palm guard. Resident R60 indicated no one has offered to apply her palm…

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 provided documents, personnel files, and staff interview, it was determined that the facility failed to ensure nurse aides who failed to become certified within four months were not working in the facility for one of five Employees (Nurse Aide Trainee Employee E12). Findings Include: Review of Title 42 Code of Federal Regulations §483.35(d) Requirement for facility hiring and use of nurse aides- §483.35(d)(1) General rule. A facility must not use any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, unless- (i) That individual is competent to provide nursing and nursing related services; and (ii)(A) That individual has completed a training and competency evaluation program, or a competency evaluation program approved by the State as meeting the requirements of §483.151 through §483.154. Review of facility provided documentation dated 11/7/24, indicated it was reported to facility administration that Nurse Aide Trainee Employee E12 failed to obtain the certified nurse aide within 120 days of working in a nurse…

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

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 develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of four residents reviewed (Resident 67). Findings include: Review of Resident R67's clinical record indicated she was admitted to the facility on [DATE], with a diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 67's Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated 4/4/24, indicated that the facility assessed Resident R67 as having a diagnosis of dementia and cognition was moderately impaired. A review of Resident R67's clinical record from 4/17/24, through 9/22/24, failed to indicate that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Interview on 11/20/24, at 1:56…

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

Based on review of facility policy, review of clinical record, observations and staff and resident interviews, it was determined that the facility failed provide food items consistent with the prescribed diet order for two of five residents observed during dining (Resident R60 and R74). Findings include: Review of facility policy Diet orders and notification of diet changes dated 8/24 indicates the first initial physician dietary order will be prescribed by the Attending physician. Review of physician orders for Resident R60 confirmed a diet order dated 8/1/23 for Regular diet, Pureed texture, Nectar/Mildly Thick consistency. During an observation on 11/19/24, at 10:02 a.m. Resident R60's was observed with a yellow, thin fluid in her cup. Interview with Licensed Practical Nurse (LPN) Employee E15 confirmed Resident R60 was not provided nectar/mildly thick consistency fluids. LPN, Employee E15 stated last week Resident R60 received regular apple juice instead of nectar/mildly thick apple juice. Interview with Director of Nursing (DON) on 11/19/24, at 10:14 a.m. confirmed Resident R60…

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 facility policy, observations, and staff interview, it was determined that the facility failed to provide adaptive feeding devices for two of five residents (Resident R74). Findings include: Review of facility policy Diet orders and notification of diet changes dated 8/24 indicates the first initial physician dietary order will be prescribed by the Attending physician. Review of clinical record indicated Resident R74 was admitted to the facility on [DATE], with diagnoses of dementia, orthostatic hypotension and acute kidney failure. Review of Resident R74's care plan dated 8/19/24, indicated provide adaptive equipment for feeding as needed: Kennedy cup with meals. During an observation on 11/18/24, at 12:15 p.m. Resident R74 did not have Kennedy cup as care planned with lunch. Interview with Registered Nurse (RN) Employee E4 confirmed the above-mentioned findings. Interview with Director of Nursing (DON) on 11/18/24, ay 2:00 p.m. confirmed Resident R74 should have had a [NAME] cup as care planned. 28…

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, resident clinical record, facility incident documentation, resident and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by not providing a two-person transfer as per physician's order for one out of eight sampled resident records (Resident R1). This was identified as past non-compliance. Findings include: The facility Abuse policy dated 2/7/24, indicated that neglect is the failure of the community, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility Lifting and transferring residents policy dated 11/20/23, indicated that it is the policy to lift and transfer residents as safely as possible. Mechanical lifts are done by two nursing or therapy personnel. All nursing team members must use the lifting devices as specified in the physician's order. Review of Resident R1's admission record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, observations, and staff interviews it was determined the facility failed to meet the daily nutritional and special dietary needs for one of six residents (Resident R1), and failed to have a structured meal delivery system to ensure residents received their meals accurately, and timely. Findings include: Review of the facility policy Dietary-Frequency of Meals and Snacks dated 12/6/23, indicated it is the responsibility of the Dining Services Department to see that each meal is served at the designated time unless there is an emergency. Review of the facility policy Skilled Nursing-Dietary Supplements dated 4/12/23, indicated it is the policy of this community that nutritional and dietary supplements will be used to complement a resident's dietary needs in order to maintain adequate nutritional status and resident's highest practicable level of well-being. Review of Resident R1's record indicated the resident was admitted to the facility on [DATE]. Review of the admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure that clinical records were complete and accurate for one of six residents reviewed (Resident R1). Findings include: Review of the facility policy Medical Records-The Medical Record date 12/12/23, indicated that the medical record will contain complete and accurate documentation, which clearly identifies the resident, justifies the diagnoses, condition, treatment, care approaches, and responses to the care provided. Review of Resident R1's admission record indicated the resident was admitted to the facility on [DATE], with the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), chronic obstructive pulmonary disease (constricted airways cause difficulty or discomfort in breathing), and congestive heart failure (the heart doesn't pump blood effectively). Review of Resident R1's current physician…

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, observations and staff interviews, it was determined that the facility failed to cover, label and date food products, properly dispose of contaminated food products, maintain the kitchen in a clean and sanitary manner, and properly wash and sanitize equipment in the Main Kitchen (Main Kitchen). Findings include: A review of facility policy Dietary' Food Receiving and Storage dated 8/23, indicated that foods shall be received and stored in a manner that complies with safe food handling practices. Foods will be covered, labeled and dated. Foods will be stored using a first in first out system. A review of facility policy Dietary- Refrigerators and Freezers dated 8/23, indicated that that all food products will be rotated according to expiration dates. Expiration dates include receiving dates and use by dates. Use by dates will be indicated on all prepared foods and food products that have been opened, A review of facility policy Dietary - Sanitation dated 8/23, indicated the food service area will be maintained in a clean and sanitary manner.…

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, observations, and staff interviews it was determined that the facility failed to properly dispose of refuse to prevent the potential infestation of rodents and insects for three of three refuse disposal containers (recycle bin, furniture and equipment dumpster, and compactor unit). Findings include: A review of facility policy Dietary- Food Related Garbage and Rubbish dated 8/23, indicated that garbage and rubbish will be disposed of in accordance with current state laws regulating such matters. Garbage and rubbish will be stored in a manner that is inaccessible to vermin. Outside dumpsters will be kept closed and free of surrounding litter. During an observation on 11/13/23, at 9:10 am the following was revealed: * the lids on the recycle dumpster were open. * the dumpster used for the disposal of furniture and equipment was uncovered and contained two bags of garbage and several disposable food containers and a pizza box. * the compactor unit was uncovered and contained bags of garbage that had not been compacted. The compactor unit was open…

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 employee personnel files, documents and staff interviews it was determined that the facility failed to employ a qualified Director of Dining Services (DDS) to manage the daily operations of the Dietary Department for 11 of 11 months. (1/23 through 11/23). Findings include: A review of the job description entitled Director of Dining Services revealed that the essential duties of the position include identifies and suggests innovative approaches and helps implement performance improvement opportunities. Education and experience requirements include Bachelor's degree preferred, or a minimum of two years related experience and training or equivalent combination of education and experience. Certification requirements include ServSafe Certification, Certified Dining Manager Certification or must obtain within one year of actively working as the Director of Dining Services. During an interview on 11/13/23, at 9:00 am Director of Dining Services (DDS) Employee E1 indicated that she has held the position of DDS since August 2022. Her certification credentials…

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, resident council group interview, resident and staff interview it was determined that the facility failed to offer residents the opportunity to vote for the November 2023 election (Second and Third floors). Findings include: The facility Resident rights-overview policy reviewed dated 6/23/23, and last reviewed 8/2023, indicated that residents have the right to exercise their rights as residents of the community and as citizens of the United States of America. During a resident council group interview on 11/14/23, at 1:00 p.m. seven out of seven residents indicated that they did not recieve assistance with voting registration for the election on November 2023. During an interview on 11/14/23, at 2:01 p.m. the Activities director Employee E3 stated that she has not been a part of voting registration process since she started her position. During an interview on 11/15/23, at 11:27 a.m. Resident R78 stated: I've been here 3-4 years. The social worker did her part to help me register. But i never received a ballot. I can't recall when that happened.…

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 records, and a staff interview, it was determined that the facility failed to notify a physician for a change in condition for one of four residents reviewed (Resident R5). Findings: A review of the Change in a Resident's Condition or Status policy dated 4/10/23, last reviewed 8/23, indicated the facility shall promptly notify the reisdent's attending physician of changes in the resident's status. It was indicated the nutse supervisor or charge nurse must notify the resident's attending physician or on-call physician when there has been a significant change in resident's physical condition. It was indicated a significant change of condition is a decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions or impacts more than one area of the resident's health status. A review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE], 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, documents and clinical records and staff interviews, it was determined that the facility failed to protect residents from physical abuse for one of two residents reviewed (Resident R12). Findings include: Review of facility policy, titled Skilled Nursing-Abuse revised August 2023, revealed, that it is the policy of the community that each resident will be free from abuse. Abuse will mean all forms of abuse, neglect, exploitation and misappropriation. None of this will be tolerated. The community will educate staff and other applicable individuals in techniques to protect all parties. Abuse allegations are reported per Federal and State law. Employees must always report any abuse or suspicions of abuse immediately to the Administrator. Review of admission record indicated that Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/3/23, indicated diagnoses unspecified dementia 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 facility policy, review of facility submitted documentation, and staff interview, it was determined that the facility failed to ensure all alleged violations involving abuse were reported immediately for one of two residents reviewed for abuse (Resident 12). Findings include: Review of facility policy, titled Skilled Nursing-Abuse revised August 2023, revealed, that abuse allegations are reported per Federal and State law. Employees must always report any abuse or suspicions of abuse immediately to the Administrator. Review of facility submitted documentation dated 10/13/23, revealed that an incident had occurred on 10/4/23, at approximately 10:30 p.m. It was reported that Nurse Aide (NA) Employee E7 told a resident (Resident R12) to shut up and applied scotch tape over resident's mouth for a few seconds and then removed it telling her Now be quiet. Further review of facility submitted report revealed that several staff members were at the nurses' station waiting on the next shift to give report. Resident R12 was exhibiting distress reactions and yelling out for help and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record, and staff interview, it was determined that the facility failed to complete a comprehensive assessment after a significant change in condition for one of five residents receiving hospice services (Resident R5). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a significant change in status assessment is required to be performed when a terminally ill resident enrolls in a hospice program and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14-days from effective date of the hospice election. A review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, cerebral palsy (a group of disorders that affect movement, muscle…

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 fourteen residents (Residents R5, R18, and R202). Findings include: Review of the facility Skilled Nursing - Comprehensive Care plans dated August 2023, previously reviewed August 2022, indicated that A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident. A review of Resident R5's clinical record indicated she was admitted to the facility on [DATE], with diagnoses that included constipation, muscle weakness, and cerebral palsy (group of disorders that affect movement, muscle tone, balance, and posture). A review of Resident R5's MDS dated [DATE], indicated the diagnosis were current. A review of Resident R5's care plan dated 11/14/23, failed to include a care plan for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and records, and staff interviews, it was determined that the facility failed to implement the bowel regimen protocol and provide treatment as required for one of four residents reviewed (Resident R5). Findings: A review of the Bowel Protocol policy dated 8/23, indicated if a resident has not had a bowel movement in two days (six shifts), non-pharmacological interventions will be initiated on the morning of day three could include prune juice, bran, applesauce. If still no bowel movement, then administer 30ml of 400mg/5ml of Milk of Magnesia (over the counter treatment for constipation), then if still no bowel movement administer 10 mg of Dulcolax suppository (a laxative that stimulates bowel movement designed to be inserted into the rectum to dissolve). It was indicated if no bowel movement still, then administer a fleet enema 19g-7g/118ml (liquid medicine used to help you have a bowel movement that is inserted into the rectum). Then, if no bowel movement, contact physician…

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 records, and a staff interview, it was determined that the facility failed to prevent pressure sore development and provide treatment as required for two of four residents (Resident R5 and R14). A review of the Dressing Change Policy policy dated 4/11/23, last reviewed 8/23, indicated it is the facility's policy to treat, measure, and track each wound individually. A review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, cerebral palsy (group of disorders that affect movement, muscle tone, balance, and posture), and anemia (deficiency of healthy red blood cells in blood). A review of Resident R5's MDS dated [DATE], indicated the diagnosis were current. Section M: Skin Conditions indicated the resident was at risk for developing pressure ulcers and did not have any current pressure ulcers. A review of Resident R5's Braden Scale for Predicating Pressure Score Risk dated 11/22/22, indicated…

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 clinical records, and staff interviews it was determined that the facility failed to ensure that the physician order indicated a catheter size for a urinary catheter (insertion of a tube into the bladder to remove urine) for two of six residents (Residents R5, R15, and R103), and failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for one of six residents (Resident R103). Findings include: Review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture), and anemia (deficiency of healthy red blood cells in blood). A review of Resident R5's Minimum Data Set Assessment (MDS, periodic assessment of resident care needs) dated 4/5/23, indicated the diagnosis were current. A review of Resident R5's physician order dated 5/26/23, indicated to change catheter as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical record, and staff interview, it was determined that the facility failed to ensure that proper hydration status was maintained by providing intravenous fluids as ordered for one of four residents (Resident R14). Findings include: Review of the clinical record revealed that Resident R14 was admitted to the facility on [DATE]. Review of Resident 14's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/3/23, indicated diagnoses of prostate cancer, dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory), and high blood pressure. Review of clinical records revealed a physician's order dated 10/23/23, for sodium chloride intravenous (IV- in the vein) solution 0.45% with 20 mEq (milliequivalent) potassium (a solution used to supply water, salt and potassium) at 60 milliliters per hour every shift for dehydration to be administered from 10/23/23 on night shift until 10/25/23 on night shift. Review of Resident R14 's progress note dated 10/25/23,…

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 and resident and staff interview it was determined that the facility failed to provide medically related social services to one of seven residents reviewed (Resident R5). Findings include: Review of facility documentation Job Description for a social worker, indicated it is the duty of the social worker to respond to each resident social needs from the time of admission throughout the resident's stay, collaborating with other staff and professionals both in and outside the facility in developing and implementing coordinated individualized plan of care and supportive services. It was indicated it is the social worker responsibility to respond to the needs of the resident and family. It stated the social work duty is to assist residents and families with end of life decision making and provide educational materials, answer questions, and assist with making hospice referral. A review of the clinical record indicated that Resident R5 was admitted to the facility 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 review of facility policies, observations and staff interview, it was determined that the facility failed to ensure that outdated biologicals were discarded in one of two medication rooms (Second Floor), and to accurately date open medications for one of four medications carts (Second floor North-East medication cart). Findings include: The facility Storage of medications policy last reviewed 8/2023, indicated that outdated medications will be removed from inventory, and that medications and biologicals are stored safely, securely and properly. During an observation on 11/14/23, at 11:50 a.m. in the Second Floor medication room with Licensed Practical Nurse (LPN) Employee E6 indicated the following: Dextrose 5% ( a solution of water and sugar adminstered via intravenous (IV) -in the vein) with an expiration date of May 2023 Central Line Tray ( used for aseptic dressing removal, cleaning and prepping of IV sites) with an expiration date of April 2023 During an interview on 11/14/23, at 11:50 a.m., Licensed Practical Nurse (LPN) Employee E6 confirmed that the facility failed…

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 policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a physician order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for three of seven residents (Resident R5, R80, and R103). 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 for Section O, Special Treatment, Procedures, and Programs: Facilities may code treatments, procedures, and programs that the resident performed themselves independently or after set-up by facility staff. Check all treatments, procedures, and programs received or performed by the resident after admission/entry or reentry to the facility and within the 14-day lookback period. Section O0100K…

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 facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that a pneumococcal immunization was offered to one of five residents (Resident R48). Findings include: Review of the facility policy Infection Prevention and Control Program dated August 2023, indicated that the pneumococcal vaccination will be offered upon admission. Review of the admission Record indicated that Resident R48 was admitted to the facility on [DATE]. Review of Minimum Data Set (MDS-periodic assessment of care needs) dated 8/25/23, included diagnoses of high blood pressure, diabetes, and weakness. Section O0300 Pneumococcal Vaccine indicated Resident R48 was not offered the pneumonia vaccination. During an interview on 11//17/23, at 11:22 a.m. the Director of Nursing confirmed that the facility failed to make certain that a resident was assessed for and offered pneumococcal immunization for one of five residents. 28 Pa. Code 211.5(f) Clinical records