Kadima Rehabilitation & Nursing At Palmyra

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that medications/biologicals were securely stored per facility policy in a medication cart on one of one nursing units. Findings include:Review of the facility policy entitled, Medication Administration, last reviewed November 2025, revealed medications were to be administered at the time they are prepared.Observations during the medication pass on March 4, 2026, at 8:47 a.m., revealed Registered Nurse (RN) 1 retrieving medication cups with labels in black marker from her cart. In an interview at that time, RN 1 confirmed she had pre-poured the medications into medication cups. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility documentation review and staff interview, it was determined that the facility failed to ensure that all required staff persons were in attendance at quarterly Quality Assurance and Performance Improvement (QAPI) committee meetings for one of two quarters reviewed.Findings include:According to the QAPI committee minutes for February 18, 2026, the Director of Nursing and the Medical Director were not present.In an interview on March 3, 2026, at 12:10 p.m., the Regional Clinical Director confirmed there is no documented evidence that the Director of Nursing and Medical Director attended the February 18, 2026, QAPI meeting. CFR 483.75(g) Quality assessment and assurance Previously cited 7/3/2528 Pa. Code 201.18(e)(1)(2)(3) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and observation, it was determined that the facility failed to provide a working call bell for one of 14 sampled residents. (Resident 10)Findings include: Clinical record review revealed that Resident 10 had diagnoses that included cerebral infarction (stroke), anxiety, and seizures. The Minimum Data Set assessment dated [DATE], indicated that the resident was dependent on staff for toileting and dressing. Review of the care plan revealed Resident 10 was at risk for falls with an intervention for staff to ensure the call light was within reach and encourage it's use. Observations on March 3, 2026 at 10:50 a.m., and 12:39 p.m., and on March 4, 2026 at 9:46 a.m., 10:35 a.m., and 11:52 a.m., revealed no call bell available. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.28 Pa. Code 211.12(d)(5) Nursing services.

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 recommendations from a consultant physician were implemented for one of four sampled residents. (Resident 1) Findings include:Clinical record review revealed that Resident 1 had diagnoses that included diabetes, history of sepsis, resistance to multiple antimicrobial drugs, dementia and chronic kidney disease. The Minimum Data Set assessment dated [DATE], indicated that he had memory impairment. On January 19, 2026, a physician ordered for an endocrinologist to evaluate and treat the resident. On January 21, 2026, a nurse practitioner endocrinologist conducted an evaluation. Review of the endocrinologist's note revealed that Resident 1 had diagnoses that included diabetes with hyperglycemia and neuropathy and Stage IV chronic kidney disease. At that time, the endocrinologist made recommendations for laboratory (lab) tests to be completed, including blood work to test his blood sugar levels and thyroid…

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 physician ordered medication was available from the pharmacy for one of four sampled residents. (Resident 2)Findings include:Clinical record review revealed that Resident 2 had diagnoses that included a traumatic brain injury, seizures, a stroke, and dysphagia (difficulty with swallowing). The Minimum Data Set assessment dated [DATE], indicated that he had memory impairment. A review of the care plan revealed a problem area of an altered neurological status due to head trauma and seizures. There was an intervention for staff to administer medications as ordered by the physician. On July 23, 2023, a physician ordered for staff to administer a scopolamine transdermal, non-invasive, patch every three days for increased secretions and to remove per the schedule. Review of the January 2026 Medication Administration Record (MAR) revealed that on January 3, 6, and 30, 2026, the scopolamine patch had not been…

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 review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess the nutritional status of six of six sampled residents at nutritional risk. (Residents 2, 9, 15, 19, 20, and 28) Findings include: Review of the facility policy entitled, Resident Weights, last reviewed May 16, 2025, revealed that reweighs would be obtained within 72 hours for a weight change of three percent (%) or greater in one month. All weights, which included reweights, would be transcribed into the resident's electronic medical record. Review of the facility policy entitled, Nutrition Management, last reviewed May 16, 2025, revealed that the facility would view muscle wasting, depression, dementia, and need for therapeutic or mechanically altered diets as potential indicators or risk factors for malnutrition. Clinical record review revealed that Resident 2 had diagnoses that included muscle weakness, dementia, and dysphagia. Review of the care plan…

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

Based on group interview, and review of facility documentation, it was determined that the facility failed to provide sufficient nursing staff to meet resident needs. Findings include: During a group interview on July 2, 2025, at 10:23 a.m., seven of seven residents reported that staff typically did not respond to call bells for an extended period of time due to low staffing levels. Review of facility staffing documentation from June 11, 2025, through July 1, 2025, revealed that the facility failed to meet the minimum nurse aide to resident ratios on 17 of 21 days reviewed. Review of facility staffing documentation from June 11, 2025, through July 1, 2025, revealed that the facility failed to meet the minimum licensed practical nurse ratios on 18 of 21 days reviewed. Review of facility staffing documentation from June 11, 2025, through July 1, 2025, revealed that the facility failed to meet the minimum registered nurse ratio on nine of 21 days reviewed Review of facility staffing documentation from June 11, 2025, through July 1, 2025, revealed that the facility failed to meet the…

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

Based on interview, it was determined that the facility failed to employ a qualified dietitian or clinically qualified nutrition professional to provide frequently scheduled consultations in the absence of a full-time qualified dietitian or clinically qualified nutrition professional. Findings include: In an interview on July 3, 2025, at 11:42 a.m., the Administrator confirmed that the facility did not employ a qualified dietitian or clinically qualified nutrition professional. CFR 483.60(a)(2) Staffing Previously cited 8/9/24 28 Pa. Code 201.18(b)(3) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, group interview, and staff interview, it was determined that the facility failed to accommodate resident preferences on the nursing unit. Findings include: Review of facility menus for the lunch meal on July 1, 2025, revealed that the meal included a dessert of apple crisp. During observation in the kitchen on July 1, 2025, at 10:51 a.m., nurse aide (NA) 1 stated that the facility did not have the ingredients to prepare apple crisp for the lunch meal. Residents were to be served applesauce as a substitute. In a group meeting on July 2, 2025, at 10:23 a.m., seven of seven residents reported they typically do not know what food was to be served with each meal. Clinical record review revealed that Resident 15 had diagnoses that included depression, anxiety, and protein calorie malnutrition. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident did not have cognitive impairment. In an interview on July 2, 2025, at 12:25 p.m., Resident 15 was observed with her lunch…

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 employ nutrition and physical therapy staff to promote the wellbeing of it's residents. Findings include: Review of clinical records revealed a lack of documentation to support that residents were being evaluated by a registered dietitian or offered physical therapy services. In an interview on July 3, 2025, at 11:29 a.m., the Administrator confirmed the facility did not employ a registered dietitian or physical therapist and that the services those positions provide were not being offered or provided to residents. 28 Pa Code 201.18(e) Management.

Based on review of the facility's assessment, facility provided documentation, and staff interview, it was determined that the facility failed to conduct and document a facility-wide assessment, using evidence-based methods, which identified the specific resources necessary to care for it's specific resident population. Findings include: Review of the Facility Assessment, last reviewed by the facility on April 30, 2025, failed to accurately identify the specific needs and services required by the various subsets and characteristics of the resident population. The Facility Assessment was incomplete after page one and failed to include the resources needed, including an evaluation of the overall number of facility staff and the capabilities needed to ensure a sufficient and competent number of qualified staff are available to meet each resident's needs. During an interview on July 3, 2025 at 11:58 a.m., the Administrator confirmed that the Facility Assessment did not contain all of the required information. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18…

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

Based on review of facility documentation and staff interview, it was determined that the facility's Quality Assurance Committee failed to meet on a quarterly basis. Findings include: Review of facility documentation revealed no evidence that the facility's Quality Assurance Committee had met since January 2025. In an interview on July 3, 2025, at 3:32 p.m., the Administrator confirmed that there was no evidence that the facility's Quality Assurance Committee had met quarterly prior to January 2025 or between January 2025 and June 2025. CFR 483.75(g) Quality assessment and assurance. Previously cited 8/9/24 28 Pa. Code 201.18(b)(3) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, observation, resident and staff interview, and group interview it was determined that the facility failed to provide care and services in a manner that respected the resident's dignity and preferences to promote quality of life for three of 16 sampled residents (Residents 9, 24, and 35). Findings include: Clinical record review revealed that Resident 9 had diagnoses that included hemiplegia and hemiparesis (paralysis) of the left side and depression. On July 2, 2025, at 11:10 a.m., the resident stated that there were no chairs in her room for visitors to sit in. At 11:30 a.m., there were no chairs observed in the resident's room. Clinical record review revealed that Resident 24 had diagnoses that included overactive bladder, age related nuclear cataract (vision impairment), and depression. On July 1, 2025, at 10:15 a.m., the resident was observed in her room in bed. She stated that she would like to be able to watch her television but no one gave her 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 resident interview and staff interview, it was determined that the facility failed to provide reasonable access to mail services as available in the community to all residents of the facility. Findings include: An interview with the resident council group conducted on July 2, 2025, at 10:23 a.m., revealed that seven of seven residents reported that the facility did not deliver mail or provide mail services on Saturdays. In an interview on July 3, 2025, at 11:56 a.m., the Nursing Home Administrator and Director of Nursing stated that although mail was delivered to the front foyer Mondays through Saturdays, the business office only delivers during their scheduled work hours.

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 notify the resident and the resident's representative of the bed hold and transfer, including the reasons for the move, and Ombudsman information, in writing upon transfer from the facility for five of six sampled residents who were transferred to the hospital. (Residents 12, 20, 28, 32, 33) Findings include: Clinical record review revealed that Resident 12 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documentation to support that the resident's representative was provided written information regarding a bed hold or the transfer to the hospital. Clinical record review revealed that Resident 20 was transferred and admitted to the hospital on [DATE] and May 7, 2025, after changes in condition. There was no documentation to support that the resident's representative was provided written information regarding a bed hold or the transfer to the hospital. Clinical…

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 in facility policy review, clinical record review, observation, review of facility documentation, and staff interview, it was determined that the facility failed to develop and implement interventions to prevent accident hazards for two of 16 sampled residents. (Residents 16 and 17) Findings include: Review of a facility policy entitled, Fall Prevention Policy and Procedures, last reviewed May 16, 2025, revealed that the interdisciplinary team would update care plan interventions promptly after fall events. Post fall management would include notification to the physician and family and completion of an incident report. Nursing was responsible to assess, document, and monitor interventions. Clinical record review revealed that Resident 16 had diagnoses that included history of stroke, difficulty walking, and muscle weakness. Review of the care plan revealed that the resident had a history of falls and staff were to ensure that the resident had non skid footwear in place at all times. Review of facility…

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

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that staff provided services consistent with professional standards, including monitoring, for one of two sampled residents receiving dialysis (process of removing excess toxins and water from the blood). (Resident 28) Findings include: Review of the facility policy entitled, Hemodialysis Policy and Procedure, last reviewed May 16, 2025, revealed staff would weigh the resident daily. Clinical record review revealed that Resident 28 had a diagnosis of end stage renal disease which required dialysis. Review of Resident 28's care plan revealed he was a risk for fluid volume changes due to dialysis with an intervention to monitor weight. Review of Resident 28's clinical record revealed a lack of evidence that Resident 28 was weighed daily. In an interview on July 3, 2025, at 1:25 p.m., the Infection Preventionist confirmed there was no documented evidence that daily weights were obtained per facility policy. 28 Pa. Code 211.12(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that pharmacy recommendations were reviewed by the physician in a timely manner for five of five sampled residents. (Residents 15, 17, 20, 21, 32) Findings include: Review of the facility policy entitled, Pharmacy Services, last reviewed May 16, 2025, revealed that a licensed pharmacist would review the drug regimen of each resident at least once per month. The pharmacist would report any irregularities to the attending physician, the Director of Nursing, and the Medical Director. The reports would be acted upon, signed off, and addressed in the physician's progress note. Clinical record review of the monthly drug regimen reviews revealed that the pharmacist made recommendations regarding Resident 15's medications on February 28, 2025. There was no evidence that the recommendations were addressed by the physician. Clinical record review of the monthly drug regimen reviews revealed that the pharmacist made recommendations regarding Resident 17'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.

Based on clinical record review, staff interview, and a confidential interview, it was determined that the facility failed to inform a resident's responsible party of treatment options that may affect the resident's well being for one of 16 sampled residents. (Resident 17) Findings include: Clinical record review revealed that Resident 17 had diagnoses that included dementia. A physician's order dated May 16, 2025, directed staff to administer an antidepressant medication, sertraline, 75 milligrams (mg) once daily. This was an increase from the previously ordered dose of 50 mg. There was no evidence that the resident's responsible party was notified of the increased dose of the medication or alternate treatment options. In a confidential interview on July 1, 2025, at 4:50 p.m., it was reported that Resident 17's responsible party was not notified of the increased sertraline dose and if they were made aware, would have declined the change. In an interview on July 3, 2025, at 11:44 a.m., the Director of Nursing confirmed that the resident's responsible party was not notified of the…

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

Based on a review of facility resident council meeting minutes and resident interview, it was determined that the facility failed to address grievances voiced by the resident group. Findings include: In a group interview conducted on July 2, 2025, at 10:23 a.m., seven of seven residents stated that call bells were not answered in a timely manner and that there had been no hairdresser in months. Review of resident council meeting minutes dated March 7, 2025, revealed that multiple residents reported that call bells were not answered timely and they would like to see a hairdresser. Review of resident council meeting minutes dated June 11, 2025, revealed that multiple residents reported that call bells were not answered timely. There was a lack of evidence that the facility had addressed the residents' ongoing concerns of call bell response times or access to a hairdresser. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for one of 16 sampled residents. (Resident 17) Findings include: Clinical record review revealed that Resident 17 had diagnoses that included dementia and hypertension (high blood pressure). A physician's order dated December 10, 2024, directed staff to administer a medication for high blood pressure (carvedilol) twice daily. Staff were to hold the medication if the resident's heart rate was less than 60 beats per minute. Review of the Medication Administration Record for June 2025, revealed that staff administered the medication when the resident's heart rate was less than 60 beats per minute on June 14, 23, and 27, 2025. In an interview on July 3, 2025, at 12:38 p.m., the Director of Nursing confirmed that the medication was given outside of parameters on those dates. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to promote healing and prevent pressure ulcers for one of 16 sampled residents. (Resident 16) Findings include: Review of a facility policy entitled, Skin and Wound Management Policy, last reviewed May 16, 2025, revealed that staff were to provide ongoing monitoring and evaluation to ensure optimal resident outcomes for residents with wounds or pressure areas or at risk for skin compromise. Clinical record review revealed that Resident 16 had diagnoses that included muscle weakness. On June 21 and 27, 2025, staff noted that the resident had newly identified open areas to the sacrum. Review of weekly skin assessments dated June 23 and 30, 2025, revealed no evidence that staff adequately assessed and measured the areas. There was no evidence that staff performed a complete weekly assessment and measurements of the resident's open areas. In interviews on July 3, 2025, at 11:51 a.m. and 2:17 p.m., the Director of Nursing stated that…

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

Based on facility policy review, clinical record review, and observation, it was determined that the facility failed to ensure that adequate catheter care was provided for one of 14 sampled residents. (Resident 20) Findings include: Review of the facility policy entitled, Urinary Catheter Care, last reviewed May 16, 2025, revealed that the urinary drainage bag must be held or positioned lower than the bladder at all times and that the catheter tubing and drainage bag must be kept off of the floor. Clinical record review revealed that Resident 20 had diagnoses that included sepsis, hematuria (blood in urine), kidney failure, and urinary retention. The resident required the use of a urinary catheter. On March 20, 2025, the physician ordered for the resident to have an indwelling catheter. Observations on July 1, 2025, at 4:51 p.m. and 5:30 p.m., revealed Resident 20 in his wheelchair with his urinary catheter drainage bag on his lap, above the level of his bladder. At 5:50 p.m. and 6:30 p.m., Resident 20 was observed at the dining room table with his urinary drainage bag on the floor.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide enteral nutrition (delivery of nutrition by a feeding tube) in accordance with resident needs for one of one sampled resident who received enteral nutrition. (Resident 35) Findings include: Clinical record review revealed that Resident 35 was readmitted to the facility on [DATE], and had a diagnosis of gastrostomy. Review of the care plan revealed that the resident required a feeding tube. A physician's order dated May 22, 2025, directed staff to administer a tube feed formula, Nutren 2.0, at 55 milliliters (ml) per hour for 18 hours. Physician's orders dated May 23 and 27, 2025, directed staff to administer a tube feed formula, Jevity 1.5, for 20 hours. There was no rate noted in the physicians order. On July 2, 2025, at 2:10 p.m., the resident was observed in bed. The tube feed pump was on and administered Jevity 1.5. The screen displayed the rate of 50 ml per hour. In an interview at 2:13…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician supervised care in a timely manner for one of 14 sampled residents. (Resident 15) Findings include: Clinical record review revealed that Resident 15 had diagnoses that included polyneuropathy, congestive heart failure, and cirrhosis of the liver. Review of the care plan revealed Resident 15 had an altered cardiovascular status related to congestive heart failure with an intervention for staff to report weight changes to the physician. Review of the clinical record revealed Resident 15 weighed 135 pounds (lbs.) on April 8, 2025, and 163.7 lbs. on May 4, 2025, a 28.7 lb. difference. On June 2, 2025, Resident 15 weighed 184.2 lbs., a 20.5 lb. difference from the previous month. There was no documented evidence that the physician was aware of the significant weight changes. In a interview on July 3, 2025 at 11:42 a.m., the Administrator confirmed that the physician was unaware of the weight changes. 28 Pa. code 211.2(d)(3) Medical director.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to serve food in a form that meets the residents needs for two of 16 sampled residents. (Resident 17 and 21) Findings include: Clinical record review revealed that Resident 17 had diagnoses that included dysphagia and dementia. A physician's order dated November 16, 2024, directed staff to provide the resident a mechanically altered diet. On June 29, 2025, staff noted that the resident was shoveling food into her mouth, pocketing the food, and coughing, and became agitated with redirection. On July 1, 2025, at 12:18 p.m., Resident 17 was observed in the dining room with her meal tray. The resident's tray ticket indicated that she was to have a mechanically soft, ground diet. The resident had consumed >75 % of the meal. The pieces of cut meat on her tray were observed to be large, they were not ground or mechanically soft. In an interview, Registered Nurse (RN) 1 stated that the pieces of meat were large and confirmed that the resident's tray ticket indicated she was to have…

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

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to ensure that adaptive equipment was provided for one of two sampled residents who required adaptive equipment for meals. (Resident 12) Findings include: Clinical record review revealed that Resident 12 had diagnoses that included tremor and muscle weakness. Review of the care plan revealed that the resident was at nutrition risk and required the use of red foam handles on silverware. A physician's order dated May 6, 2025, directed staff to provide red foam handles on silverware at all meals. On July 2, 2025, at 12:28 p.m., the resident was observed in her room with her lunch tray. The red foam handles were not in place. The resident reported that she was not provided the red foam handles at the breakfast meal that morning either. In an interview on July 3, 2025, at 11:44 a.m., the Director of Nursing confirmed that the resident should have been provided with the red foam handles for the silverware with her meal. 483.60(g) Assistive devices. Previously cited…

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

Based on clinical record review and staff interview it was determine the facility failed to maintain clinical records that were complete and accurate for three of 11 sampled residents. (Residents 1, 9, 11)Findings include: Clinical record review revealed that Resident 1 had diagnoses that included iron deficiency anemia, muscle wasting, and osteomyelitis. In an interview on August 22, 2025, at 4:05 p.m., the Administrator stated that the resident was seen by the wound consultant on August 12 and 19, 2025, and the assessments should have been scanned into the resident's clinical record. There was a lack of evidence in the resident's clinical record that the resident was seen by the wound consultant on those dates. Clinical record review revealed that Resident 9 had diagnoses that included Parkinson's disease. In an interview on August 22, 2025, at 4:05 p.m., the Administrator stated Resident 9 was seen by the wound consultant on August 12 and 19, 2025, and that the assessments should have been scanned into the clinical record. There was a lack of evidence in the resident's clinical…

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

Based on clinical record review, staff interview, and review of hospital records, it was determined that the facility failed to readmit a resident after a transfer to the hospital for one of three sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 resided in the facility since October 29, 2024, and had diagnoses that included heart failure, kidney disease, diabetes, depression, and a history of suicidal behavior. On April 29, 2025, a nurse noted that the resident was found biting on the cord to her bed control and that she stated, I want to kill myself. The resident was transferred to the hospital for a psychiatric evaluation. According to the hospital records, the resident was evaluated in the hospital by the psychiatrist and was deemed safe to return to the facility on May 3, 2025. Hospital records further indicated that the facility informed them that they would not take the resident back. In an interview on May 30, 2025, at 9:50 a.m., the Regional Director of Operations for the facility confirmed that they failed to readmit 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 facility policy review, clinical record review, and observation, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for three of four sampled residents. (Residents 2, 3, and 4) Findings include: Review of the facility policy entitled, Covid-19 Policy and Procedure, last reviewed February 5, 2025, revealed personal protective equipment (PPE) was to be worn when caring for residents who tested positive or had potentially been exposed to Coronavirus Disease 2019 (COVID-19). PPE was to include gloves, a gown, a face mask, and a face shield. Precautions were to remain in place for at least 14 days and up to 20 days, depending on severity of the residents' symptoms. Observations on February 14, 2025, at 10:00 a.m., revealed one cart containing PPE supplies was centrally located in each of the three resident occupied hallways. Two signs hung on the room doors of Residents 2, 3, and 4, indicating droplet and contact precautions were to be followed when entering the room. The signs instructed staff to clean hands before…

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 interview, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. Findings include: During an interview on August 6, 2024, at 10:50 a.m., the Administrator stated that the facility did not employ a certified dietary manager. The Administrator also stated that there was not a full-time registered dietitian at the facility. There was no evidence that the facility employed a certified dietary manager in the absence of a full-time qualified dietitian. 28 Pa Code 201.18(e)(1)(6) Management.

Based on observation and review of facility policy, it was determined that the facility failed to store food under sanitary conditions in the kitchen. Findings include: Review of the facility policy entitled, Food Storage, last reviewed August 1, 2024, revealed that food storage areas should be maintained in a clean, safe, and sanitary manner. Observation of the kitchen during a tour on August 6, 2024, at 9:30 a.m., revealed a container of sugar with a plastic cup stored inside the container, directly touching the sugar in the dry storage area. In refrigerator 1 there were four heads of lettuce in a bag dated July 17, 2024, that were turning brown and an opened, undated container of ice cream with a soiled spoon next to it. The walk-in freezer contained a large accumulation of ice buildup that was covering food items and there was trash on the floor. CFR 483.60 Food Procurement Store/Prepare/Serve-Sanitary. Previously cited 9/3/23 28 Pa. Code 201.18(b)(3) Management.

Based on policy review and staff interview, it was determined that the facility did not have a credentialed Infection Preventionist (IP). Findings include: Review of the facility policy entitled, Infection Control, last reviewed August 1, 2024, revealed that the facility staff was to report all infections to the IP, who would then conduct routine surveillance. In an interview on August 6, 2024, at 9:47 a.m., the Director of Nursing stated that the facility had no staff that were credentialed infection preventionists. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, it was determined that the facility failed to ensure that a dignified environment and services were provided to promote quality of life on the nursing unit. Findings include: Observation on the nursing unit revealed a bulletin board outside of the dining room displaying the menus for breakfast, lunch, and dinner. On Tuesday August 6, 2024, and Wednesday August 7, 2024, the menus posted were labeled Monday and incorrectly identified what was to be served at each meal. Observations on August 6, 2024, from 10:30 a.m. through 12:45 p.m., and on August 7, 2024, from 11:00 a.m., through 12:45 p.m. revealed that the clock in room [ROOM NUMBER] above Resident 8's bed displayed the incorrect time.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained on one of one nursing units. Findings include: Observation of the ice machine on August 6, 2024, at 10:09 a.m., revealed an electrical outlet pulled out from the wall, ripped siding on the ice machine and a dirty floor. Observations on August 6, 2024, at various times, revealed a bulletin board in the hallway next to room [ROOM NUMBER] with peeling cork, stained ceiling tiles outside of room [ROOM NUMBER], and a missing cover from the baseboard heater in room [ROOM NUMBER]. Observations on August 8, 2024, at various times, revealed a floor tile missing by the bathroom door in room [ROOM NUMBER], the paint was scratched and marred behind bed 'D' in room [ROOM NUMBER], a tear in the linoleum floor at the foot of bed 'A,' and a white substance on the wall by the soap dispenser in room [ROOM NUMBER]. CFR 483.10(1)(iii) Clean, safe, comfortable environment Previously cited 9/7/2023

Based on observation, policy review, and staff interview, it was determined that the facility failed to ensure that licensed nurses (a licensed practical nurse) maintained professional standards of quality care in the administration of medications set forth in the Pennsylvania Code Title 49, Professional and Vocational Standards for one of two medication carts. (West hall) Findings include: Review of the facility policy entitled, Specific Medication Administration Procedures and eMAR Backup, last reviewed August 1, 2024, revealed that nurses were to use the Medication Administration Record (MAR) to verify medication and document when medications were administered. If the facility's electronic MAR (eMAR) was not functioning, staff was to print a paper MAR to ensure accurate administration and documentation of medications. On August 7, 2024, LPN2 was observed administering medication to the residents in the [NAME] hall. At that time, she stated that the eMAR was not working when she began her medication pass and she administered all the oral medications without using a backup paper…

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 and observation, it was determined that the facility failed to ensure that medications/biologicals were securely stored in one of two medication carts on the nursing unit. (East cart) Findings include: Review of the facility policy entitled, Storage of Medication, last reviewed August 1, 2024, revealed that the medications were to be stored securely and accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies were to be locked or attended by persons with authorized access. Observations on August 8, 2024, from 9:20 a.m. through 9:45 a.m. revealed the licensed nurse (LPN1) passing medications on the nursing unit. At various times throughout the observation LPN1 left the medication cart unlocked, unattended, and accessible to anyone in the vicinity. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, personnel file review, and staff interview, it was determined that the facility failed to provide abuse training upon hire as per facililty policy for one of five sampled employees. (Employee 3) Findings include: Review of the facility policy entitled, Abuse Protection, last reviewed August 1, 2024, revealed that residents had the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. The facility was to have processes in place that included mandated staff training/orientation programs that included topics such as abuse prevention, identification, and reporting of abuse at the time of hire, annually, and as needed. Review of the personnel file for newly hired Employee 3, who was hired July 8, 2024, revealed that there was no documented evidence that the employee had abuse training or orientation upon hire. In an interview on August 9, 2024, at 12:55 p.m., the Administrator confirmed that there was no documented evidence that Employee 3 had received…

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, clinical record review, facility policy review, and staff interview, it was determined that the facility failed to store respiratory equipment appropriately for one of 14 sampled residents. (Resident 12) Findings include: Review of the facility policy entitled, Departmental (Respiratory Therapy) - Prevention of Infection, last reviewed August 1, 2024, revealed that medication nebulizers were to be stored in a plastic bag marked with the resident's name and date between uses. The tubing and medication administration equipment was to be discarded every seven days. Clinical record review revealed that Resident 12 had diagnoses that included asthma. On October 31, 2023, the physician ordered that staff administer an inhalation nebulization solution via a nebulizer two times a day. Observations on August 6, 2024, through August 9, 2024, at various times revealed Resident 12's nebulizer was unbagged in a basin with other items on the floor. In an interview on August 9, 2024, at 11:00 a.m., the Director of Nursing confirmed that nebulizers were to be stored in a…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the pharmacist's recommendations were acknowledged by the physician for one of 14 sampled residents. (Residents 12) Findings include: Clinical record review revealed that Resident 12 had diagnoses that included depression and insomnia. On November 1, 2023, the physician ordered that staff administer sertraline (an antidepressant) twice a day. On April 9, 2024, the pharmacist noted that Resident 12's sertraline was due for an assessment to see if the dose could be gradually reduced and if not a rationale was to be provided. There was no documented evidence that the physician responded to the pharmacist's recommendation. In an interview on August 9, 2024, at 11:15 a.m. the Director of Nursing confirmed that there was no documented evidence that the physician acknowledged the pharmacist's recommendation. CFR 483.45(c)(iii) Drug Regimen Review. Previously cited 9/7/23 28 Pa. Code 211.12(d)(3)(5) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and resident and staff interviews, it was determined that the facility failed to offer routine annual dental services and emergency dental care for one of 14 sampled residents. (Resident 25) Findings include: Clinical record review revealed that Resident 25 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus, dysphagia (difficulty swallowing), and aphasia (difficulty communicating) following a stroke. Review of the Minimum Data Set assessment, dated May 3, 2024, revealed the resident was mildly cognitively impaired. On March 19, 2024, the physician ordered a dental evaluation and treatment for the resident. In an interview on August 6, 2024, at 11:14 a.m., Resident 25 stated that he had not been seen by a dentist while at the facility and would like a dental appointment. There was a lack of documentation to support that the resident received dental services as ordered. In an interview on August 8, 2024, at 11:35 a.m., the Administrator 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 clinical record review, observations, and resident interview, it was determined that the facility failed to provide sufficient and fresh fluids consistent with resident needs and preferences for four of 14 sampled residents. (Residents 1, 8, 10, 12) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included Alzheimer's disease and depression. Review of Resident 1's current care plan revealed that she was nutritionally at risk and that staff was to monitor for signs and symptoms of dehydration. On August 8, 2024, at 12:30 p.m., Resident 1 was observed in her room with a cup containing warm water dated 8/7 in front of her on her bedside table. Clinical record review revealed that Resident 8 had diagnoses that included dehydration and urine retention. Review of Resident 8's current care plan revealed that she was at risk for dehydration and urinary tract infections. An intervention was for staff to promote and encourage fluid consumption. On August 8, 2024, at 12:35 p.m., Resident 8 was observed in her room with a cup containing warm water…

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

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide therapeutic diets as ordered by the physician for two of 14 sampled residents. (Residents 8, 12) Findings include: Clinical record review revealed that Resident 8 had diagnoses that included dysphagia and hypertension. A physician's order dated March 11, 2023, directed staff to provide a mechanical soft diet. Review of the care plan revealed that the resident received a mechanically altered diet. Review of a speech therapy evaluation dated July 1, 2024, revealed that the resident received a mechanical soft chopped meat and ground texture diet. Observation on August 8, 2024, at 12:20 p.m., revealed that the resident was served Salisbury steak, mashed potatoes, and California blend vegetables. The Salisbury steak was in a whole patty form. Review of the Resident 12's meal ticket revealed that she was to receive ground Salisbury steak. In an interview on August 8, 2024, at 12:40 p.m. the speech therapist stated that Resident 12 should have received 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 clinical record review and observation, it was determined that the facility failed to provide adaptive equipment to assist with eating meals for one of 14 sampled residents. (Resident 12) Findings include: Clinical record review revealed that Resident 12 had diagnoses that included tremors and depression. On April 10, 2024, the physician ordered for staff to provide a plate guard with all meals. The care plan indicated that the resident was at nutrition risk and staff was to provide a plate guard with all meals. On August 6, 2024, August 7, 2024, and August 8, 2024, from 12:15 p.m. through 12:30 p.m. Resident 12 was observed eating her lunch in her room. She did not have a plate guard. In an interview on August 6, 2024, at 12:20 p.m. Resident 12 stated that the plate guard helped her with self-feeding and that she rarely received it. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident interview, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment in nine of 16 resident rooms on the nursing unit. (Rooms 104, 106, 107, 108, 114, 115, 116, 117, 118) Findings include: Observation on the nursing unit on April 27, 2024, at 1:30 p.m. revealed the following: In room [ROOM NUMBER] the paint was chipped and peeling on the radiator cover. In room [ROOM NUMBER] there was an area of mismatched floor tiles and large ruts in the floor in the area of the D bed. Resident 2 stated that her wheelchair frequently gets stuck in the ruts in the floor. The call light notification outside of room [ROOM NUMBER] did not light up when the residents in the room rang their call bell. The door of room [ROOM NUMBER] had peeling paint. In room [ROOM NUMBER] there were stained ceiling tiles. Outside of room [ROOM NUMBER] on the wall underneath the hand sanitizer was an area missing paint. In room [ROOM NUMBER] the paint was peeling on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to provide necessary equipment to a resident on admission for one of five sampled residents. (Resident CL1) Findings include: Review of the the facility policy entitled, Pre-admission Process Procedure, last reviewed July 1, 2023, revealed that when a referral was received the Clinical Director of Admissions and Marketing would pre-screen the referral. The Director of Nursing would review the referral clinically for staff education needs and to ensure all necessary equipment was ordered. If there were additional needs identified, they would be communicated to the Clinical Director of Admissions and Marketing so they could be addressed before admission. Clinical record review revealed that Resident CL1 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease, dependence on supplemental oxygen, and morbid obesity. Review of pre-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.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of five sampled residents. (Resident CL1 ) Findings include: Clinical record review revealed that Resident CL1 had diagnoses that included chronic obstructive pulmonary disease, congestive heart failure, and morbid obesity. A physician's order dated April 21, 2024, directed staff to administer an inhaler (Symbicort) two times a day to treat the resident's wheezing. A review of the April 2024 Medication Administration Records revealed that there was no evidence that staff administered the inhaler as ordered on April 21 and 22, 2024. In an interview on April 27, 2024, at 2:05 p.m., the Nursing Home Administrator confirmed that there was no documented evidence that Resident CL1 received the inhaler as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, and staff interview, it was determined that the facility failed to implement care planned interventions for two of three sampled residents. (Residents 1, 3) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included diabetes and peripheral vascular disease (a circulation disorder). On January 29, 2024, the resident received diabetic foot support sneakers. The foot specialist recommended frequent foot examinations to identify pressure areas and for foot health. A review of the care plan revealed that staff were to check the resident's feet for signs of pressure or indentation and to relieve pressure on the resident's feet every two hours. Review of the clinical record revealed there was a lack of documentation to support that staff checked the resident's feet as per the care plan. In addition, the care plan indicated that the resident had the potential for impaired skin integrity, and staff were to check the resident's skin every shift for the development of open areas, scratches, cuts, and/or bruises and report…

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 a care plan, and to provide ongoing assessment and monitoring for one of two sampled residents receiving dialysis (process of removing excess toxins and water from the blood). (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included end-stage renal disease. On February 8, 2024, a physician ordered for the resident to receive dialysis three times a week at an offsite facility. Review of the resident's current care plan revealed that dialysis was not an included care area and no interventions were developed to address Resident 1's dialysis three times a week. In a confidential interview, staff stated that residents who receive dialysis are to have a book with dialysis communication forms. The forms included pre and post dialysis weights, vital signs and recommendations from the center. There was a lack…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interview, and observation, it was determined that the facility failed to provide wound treatments for one of four sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease and diabetes mellitus. Review of the wound consultant's notes revealed that the resident had a pressure wound to his left posterior thigh. On December 15, 2023, the physician ordered for staff to apply a treatment and dressing daily to Resident 1's wound. In an interview on December 19, 2023, at 11:10 a.m., Resident 1 stated that staff do not always complete treatments to his wound. On December 19, 2023, at 11:30 a.m., Resident 1's left leg was observed with a dressing applied to his left posterior thigh. The dressing did not contain a date. Review of Resident 1's December 2023, treatment administration record revealed a lack of documentation 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 clinical record review and observation, it was determined that the facility failed to provide services to maintain adequate grooming and personal hygiene for residents who need assistance with activities of daily living for two of four sampled residents. (Residents 1, 2) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included diabetes mellitus and osteoarthritis. The Minimum Data Set assessment dated [DATE], indicated that the resident required staff assistance and/or supervision for personal hygiene. The care plan identified that Resident 1 had difficulty caring for himself and interventions included that staff assist with activities of daily living. Observation on December 10, 2023, at 10:45 a.m., revealed that Resident 1's fingernails on both hands were long and jagged with dirt underneath. In an interview at that time, Resident 1 stated that his nails are longer than he would like and that they needed to be trimmed. Clinical record review revealed that Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of five sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus and congestive heart failure. On August 10, 2023, the physician ordered for staff to check Resident 1's blood glucose weekly. Review of the current care plan indicated that the resident had the potential for hypoglycemia and hyperglycemia with an intervention to check his blood glucose as ordered. There was no documented evidence that the physician order was ever implemented. Further review of Resident 1's clinical record revealed that on August 31, 2023, the nurse practitioner assessed the resident and noted that he had bilateral knee pain and ordered an orthopedist consult. There was no documented evidence that Resident 1's orthopedist consult was ever completed. In 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 clinical record review and staff interview, it was determined that the facility failed to follow safety measures for one of five sampled residents. (Resident 3) Findings include: Clinical record review revealed that Resident 3 was admitted to the facility with diagnoses that included diabetes mellitus, dementia, and a history of falling. Review of the current care plan revealed that the resident had impaired cognitive function, was at risk for falls and skin impairment, and needed assistance from staff for activities of daily living. Interventions were for staff to have Resident 3's bed in the lowest position while he was in bed and to apply a pressure relieving cushion to his wheelchair. Review of the nursing notes indicated that the resident fell from bed on November 13, 2023. It was noted that the resident's bed was not in the lowest position at the time of the fall. On November 15, 2023, Resident 3 fell from his wheelchair in the dining room. The nurse's note indicated that upon inspection the resident's cushion was not properly secured to his wheelchair. In 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.