Aristacare At East Falls

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for one of two residents sampled for post-traumatic stress disorder(PTSD). (Resident R7).Findings include:A review of the clinical record revealed that Resident R7 was admitted to the facility on [DATE] with diagnoses to include traumatic subarachnoid hemorrhage (a collection of blood that accumulates between the inner layer of the skull), traumatic brain injury (occurs when external force causes damage to the brain), and post-traumatic stress disorder (PTSD) (a mental health condition that develops after experiencing or witnessing a traumatic event, such as a natural disaster, war, violent crime, or personal loss).Resident R7's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A review of the facility policy titled, Isolation-Initiating Transmission-Based Precautions undated, revealed Transmission-Based Precautions will be imitated when there is reason to believe that a resident has communicable infection disease. Transmissions-Base Precautions may include Contact Precautions, Droplet Precaution, or Airborne precautions:A review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], with a physician's order on the same date for tracheostomy and hemodialysis. The clinical record also included special instructions for enhanced barrier precautions due to open insertion sites related to these treatments.On October 16, 2025, at 9:19 a.m., a tour with the Assistant Director of Nursing and Infection Preventionist, Employee E2, revealed that the facility provides bedside hemodialysis to residents. All such residents have special instructions to follow transmission-based precautions, and all staff entering their rooms must wear personal protective…

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

Based on observations, review of facility documentation, staff and resident interviews, it was determined that the facility failed to provide an ongoing program of activities to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities for three of three residents reviewed. (Residents R14, R18 and R21).Findings include:Interview with residents during resident council meeting held on July 29, 2025, at 11:00 a.m. with Resident R14, R18 and R21 stated they do not have any activity program in the facility.Resident R21 stated the facility were supposed to provide his favorite group program like Bingo but the facility did not provide any group activities lately.Resident R18 stated the last activity program she attended was on July 4, 2025 and no other activity program since then.Resident R14 stated she did not attend any activity program.Review of July 2025 activity program revealed that there were no group activities on weekends, the only activity program listed on weekend was Independent Leisure.Observation 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 clinical records and facility policies, observations and staff interviews, it was determined that the facility failed to timely and consistently provide recommended and/or prescribed treatment and services, consistent with professional standards of practice, to prevent new pressure sore development, promote healing and prevent worsening of existing pressure sores related to turning and repositioning for three of seven residents reviewed. (Resident R52, R47 and R5)Findings include:Review of care plan for Resident R52 dated July 25, 2023, revealed that resident was totally dependent on staff to turn and reposition in bed every 2 hours.Review of physician order for resident R52 dated May 3, 2025, revealed an order to turn and reposition every 2 hours. Observation of Resident R52 on July 29, 2025, at 10:20 a.m. revealed that the resident was lying in bed on her back with one pillow on the left side and one pillow under the right hand. There was a wedge cushion on the floor to the left side of the bed. Further observation of Resident R52 on July 29, 2025, at 12:22…

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

Based on the review of facility staffing schedule, clinical records, and interviews with staff, residents and resident representative, it was determined that the facility failed to ensure sufficient nursing staff to provide nursing related to interventions to prevent pressure ulcer and restorative nursing services for four of seven residents reviewed. (Residents R52, R47, R5, and R6)Review of an undated facility policy Prevention of Pressure Ulcers, revealed that Identify risk factors for pressure ulcer development 2. For a person in bed. a. Change position at least every two hours or more frequently if needed.Interview with Resident R14, R18 and R21 during resident council meeting held on July 29, 2025, at 11:00 a.m., stated the facility did not have sufficient staffing. Residents stated call bells often take longer to answer and sometimes it could even take one or two hours. Residents also stated activities of daily living (hygiene, mobility, dining-eating, communication) take longer due to low staffing.Interview with Resident R49's representative on July 31, 2025, at 3:08 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 personnel files and staff interviews, it was determined that the facility failed to ensure that staff demonstrated competency in skills and techniques necessary to care for residents with a restraint in bed and during medication administration via gastrointestinal tube for four of four nursing staff reviewed. (Employees E4, E14, E17 and E18)Findings include:Observation of Resident R23's room on July 28, 2025, at 11:28 a.m. revealed that the resident was using a fully enclosed Posey Net Bed.Review of manufacture recommendation for Posey Bed revealed that the Posey Bed is a restraint, and must be prescribed by a licensed physician, for use only in healthcare facilities. Improper use of the Posey Bed 8070/8075 may lead to serious injury or death. Patient monitoring should be determined by hospital protocol, a doctor, and the patient care plan. The Posey Bed 8070/8075 is a hospital bed, canopy and mattress system designed to help provide a safe, controlled environment for patients at extreme risk…

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

Based on observation, review of clinical record, interview with staff, and review of facility policy, it was determined that the facility failed to ensure that medications and biologicals are labelled and stored in a safe and secure manner for medication storage areas in two of two nurses' stations observed. (West and East side nurse stations) Findings include: Review of facility policy on Storage of Medications section Policy Statement revealed that AristaCare at East Falls shall store all drugs and biologicals in a safe, secure, and orderly manner. Under section Policy Interpretation and Implementation #3. Drug containers that have missing, incomplete, improper or incorrect labels shall be returned to the pharmacy for labelling before storing. #4. AristaCare at East Falls shall no use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. #7. Compartments (including but not limited to. Drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be a locked when…

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

Based on observations, clinical record reviews, facility documentation and interviews with staff, it was determined that the facility failed to ensure that a physical restraint was used according to the professional standards of practice for one of two residents reviewed. (Resident R23).Findings include: Review of an undated facility policy Use of Restraints, revealed that Physical Restraints are defined as by the Centers for Medicare and Medicaid_ Services (CMS) as any, manual method or physical or mechanical device, material or equipment attached or adjacent to the residents body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. The definition of a restraint is based on the functional status of the resident and not the device. If the restraint cannot remove a device in the same manner in which the staff applied it given that residents physical condition i.e., side rails are put back down, rather than climbed over), and this restricts his/ her typical ability to change position or place, that device is considered…

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, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated transfers to the hospital in writing, for one of three clinical records reviewed. (Resident R56)Findings include:Review of Resident R56's clinical record revealed that Resident R56 was discharged on May 8, 2025.Upon request, the facility was not able to produce proof that the facility sent a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman.Interview with Employee E1, Administrator, conducted on July 31, 2025, at 3:00 p.m. revealed the facility did not have proof that the facility sent a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. Administrator stated facility could not locate any discharge notification for the month of May 2025.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(2) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of clinical records and facility policies it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for one resident related to restorative therapy and range of motion for two of 22 resident records reviewed (Resident R6 and Resident R11). Findings include:Review of the facility Care Plan policy indicated an individualized care plan includes measurable objectives and timetables to meet the Resident's medical, nursing, mental, and psychological needs is developed for each resident. Review of the facility policy on Care Plans section Policy revealed that an individualized care plan that include measurable objective and timetable to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Under section Policy Interpretation and Implementation. #1. AristaCare at East Falls Planning/Interdisciplinary Team, in coordination with the resident, his/her family, or representative develops and…

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

Based on interview with resident's representative, staff interview and review of clinical records, it was determined that the facility failed to provide showers for one of five residents reviewed dependent on staff for activities of daily living. (Resident R49)Findings include:Clinical record review for Resident R49 revealed that his admission diagnoses included dependence on respirator and functional quadriplegia.Review of Resident R49's quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 3, 2025, revealed that Resident R49 was totally dependent on staff for activities of daily living to include bed mobility, transfers, toilet use and showers.Continued review of the MDS revealed that the resident's cognition was severely impaired with a BIMS score of 99 (Brief Interview for Mental Status - a tool to assess cognitive function; a score of 99 which indicates the resident was unable to complete interview). The MDS indicated that Resident R1 was rarely/never understood by others when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interviews with resident and staff, and review of clinical records and facility policy it was determined the facility failed to ensure rehabilitative nursing care was provided to one of 14 resident records reviewed (Resident R6)Findings include:Review of the facility policy titled Rehabilitative Nursing Care, undated, states that rehabilitative nursing care is provided for each resident admitted , nursing personnel are trained in rehabilitative nursing care to assist each resident to achieve and maintain an optimal level of self-care and independence and is performed daily who require such service. Furthermore, the same policy states the residents' care plan, the goals of rehabilitative nursing care are reinforced. Review of Resident R6's clinical records revealed the resident was admitted to the facility on [DATE]. 2024 and was diagnosed with hemiplegia and hemiparesis (paralysis of one side of the body) following unspecified cerebrovascular disease affecting the right dominant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interviews, review of clinical records and facility documentation and policy it was determined the facility failed to adequately supervise a resident who left the facility without notice for one of 14 resident records reviewed (Resident R8).Finding include: Review of facility policy titled Elopement undated states, Staff shall investigate and report all cases of missing residents. 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse, DON, or Administrator. 2. If an employee observes a resident leaving the premises he/she should: Attempt to prevent the departure in a courteous manner. Get help from other staff members in the immediate vicinity, if necessary. Instruct another staff member to inform the charge nurse, DON, or Administrator that a resident has left the premises. Employee should go with the resident and stay with them when applicable or needed, call 911 for assist 3. When a departing individual returns to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, review of clinical record, review of facility policy and competencies, revealed that the facility did not ensure that checks for proper placement of gastric tubes were conducted before medication administration via gastric tube for one of three residents observed. (Resident R59)Findings include:Review of facility competency on Medication administration-through a feeding tube #5. Checks tube for placement, and patency prior to administration of meds.Review of facility policy on Confirming Placement of Feeding Tube revealed that under section Purpose: The purpose of this procedure in to ensure proper placement of the feeding tube to prevent aspiration during feeding. Under section Steps in the Procedure: #4. Attach 50 to 60 cc syringe with 10 cc of air to the end of the tube. #5. If tube is clamped, unclamp, #6. Place stethoscope 2 to 3 inches below the xyphoid process. #7. Forcefully inject 10 cc of air into the tube while listening to the abdomen with stethoscope for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical record, staff interview and review of facility policy, it was determined that the facility did not ensure that residents receive oxygen according to physician's orders for one of two residents reviewed. (Resident R11)Findings include: Review of facility policy on Oxygen administration under section Purpose: The purpose f this procedure is to provide guidelines for oxygen administration. Under section Preparation: #1. Verify that there is a provided order for this procedure. Review the physician's order or facility protocol for oxygen administration. #2. If resident requests it due to shortness of breath etc., a provider will be notified. Review of Resident R11's clinical record revealed that Resident R11 was admitted to the facility on [DATE], with diagnoses of but not limited to Acute and Chronic Respiratory Failure with Hypoxia (low levels of oxygen).Further review of Resident R11's clinical record revealed that Resident R11 did not have a physician's order 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.

Based on the review of facility documentation, review of personnel files and interview with staff, it was determined that the facility failed to complete performance review of every nurse aide at least once every 12 months for five of five employees reviewed. (Employees E18, E19, E20, E21 and E22)Findings include:A request was made to the facility Nursing Home Administrator and Director of Nursing for annual training records for five Nurse Aides, Employees E18, E19, E20, E21 and E22 on July 31, 2025.Facility did not performance evaluation record for Employees E18, E19, E20, E21 and E22.Interview with the facility Administrator on July 31, 2025, at 3:00 p.m. confirmed that did not have performance evaluation of Employees E18, E19, E20, E21 and E2228 Pa. Code 201.18(b)(1)(3) Management28 Pa. 211.12(c) Nursing services

Based on clinical record review, and staff interviews it was determined that the facility failed to ensure each resident is provided with the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one resident of 13 resident records reviewed (Resident 46).Findings Include: Review of Minimum data set assessment (MDS-periodic assessment of resident's care needs), dated July 10, 2025, indicated that resident had a BIMS (Brief Interview for Mental Status-a screening assessment to aid in in determining cognitive impairment) score of 0 that indicated that resident's cognitive status was severely impaired. Review of clinical record for Resident R46 dated July 16, 2025 revealed that the resident noted to be yelling out a times, yelling at staff at times, as needed meds given, effective for about 3 hours, resident continue to yell out at times, offered to sit in chair, resident refuse, repositioned, refuse to allow staff to place helmet on head, continue to be educated on the importance of having helmet 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 upon review of clinical records, facility's pharmacy reviews, and policy it was determined the facility failed to act upon the irregularities noted by the pharmacist in a timely manner for four of 14 resident records reviewed (Residents R2, R4, R7, R8). Findings include:Review of the facility's Pharmacy Consultant Policy and Procedures, undated, states the Consult Pharmacist evaluates the residents' medication orders and submits a report to the Nursing Home Administrator and Director of Nursing which the facility has seven days to implement the pharmacist recommendation. Resident R2 was admitted to the facility on [DATE], with physician orders, dated April 15, 2025, for 0.5 milligrams (mg) of Clonazepam, instructed to give 1mg every 12 hours as needed for anxiety.Review of Resident R2's pharmacy review revealed on April 16, April 29, May 27, and June 24, 2025, indicated the order duration must be specified for a PRN (as needed) psychoactive medications and that the first order is limited to only 14 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.

Based on observation, interview with staff and review of facility policy, it was determined that the facility failed to maintain an effective infection control program to prevent the development and transmission of communicable diseases for one of one resident observed for tracheostomy care. (Resident R54)Findings include:Observation of Resident R54 during Tracheostomy care observation conducted June 30, 2025, at 10:46 with Employee E8 revealed that EmployeeE8 prepared the tracheostomy care materials by placing placed a paper towel on top of the bed, proceeded to put clean, gauzes and all the supplies on top of the paper towel. Started suctioning, started cleaning the stoma with gauze taken from on top of the paper towel, placed the used gauze back on the paper towel on top of the clean items, proceeded to pick up gauze from the paper towel and placed them on the paper towel together with clean items-dirty gauze on top of clean gauzeInterview with Licensed nurse, Employee E8 conducted at the time of the observation confirmed that he placed dirty gauzes on top of clean treatment…

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

Based on review of clinical records and interview with staff, it was determined facility did not maintain medical records according to professional standards of practice for one of ten residents reviewed (Resident R3) Findings include: Review of facility policy charting and documentation, indicates that all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Further review of policy indicates that documentation of procedures and treatments shall include care-specific details and may include: the name and title of the individual who provided care; how the resident tolerated treatment /procedure; whether the resident refused the procedure/treatment; notification of family, physician or other staff, if indicated and the signature and title of the individual documenting. Review of R3's clinical record on Monday, June 9, 2025, revealed a resident with medical history of anoxic brain injury (when brain doesn't receive enough oxygen), contracture of left hand, contracture of right hand,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and a review of facility policies and documentation, it was determined that the facility was not maintaining an effective pest control program. Findings include: A review of the undated facility Pest Control policy revealed that it states that the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. A review of facility grievance report, dated April 17, 2025, revealed that a resident was sent back to the facility from an appointment at the hospital due to a bedbug being found on the resident causing his appointment to be cancelled. A review of pest control logs and reports from the pest control company revealed no further reports of follow up on this incident. A review of the pest control company's reports revealed that on May 28, 2025, the pest control company was called to the facility to for a bedbug found in room [ROOM NUMBER] which was checked by the pest control technician. The nurse had stored the bedbug in a specimen cup…

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 job's descriptions, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility to ensure that the facility provides treatment and services consistent with professional standards of practice, to prevent pressure ulcers which resulted in the development of pressure ulcer/s for Resident R2, R3 and R8. The facility failed to provide treatment and services consistent with professional standards of practice to promote healing and prevent infection which resulted in worsening/deterioration of pressure ulcers for R1, R2, R3, R4, R6, R7, and R8. The failure of not properly preventing, managing, and treating pressure injuries placed the residents at the facility at high risk for harm and resulted in an Immediate Jeopardy situation. Findings include: Review of the job description of the Nursing Home Administrator (NHA) revealed that, The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, interviews with staff and hospital staff, reviews of hospital records, electronic communication records and facility policies and procedures, it was determined that the facility failed to permit one of one resident's reviewed to return to the facility after hospitalization. (Resident R10) Findings include: Review of the undated policy titled Holding Bed Space revealed that AristaCare at East Falls shall inform residents upon admission and at a transfer for hospitalization or therapeutic leave of our bed-hold policy. Upon admission and when a resident is transferred for hospitalization or for therapeutic leave, a representative of the building will provide information concerning our bed-hold policy. 2. When emergency transfers are necessary, AristaCare at East Falls will provide the resident or representative (sponsor) with information concerning our bed-hold policy of such transfer. 3. The bed-hold information will include any charges that the resident may incur as well as 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 the review of clinical records, facility documentation, interview with staff, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care of residents with wounds for one of two employee records reviewed. (Employee E8). Findings Include: Review of clinical records revealed that the facility did not provide treatment and services consistent with professional standards of practice, to prevent pressure ulcers which resulted in the development of pressure ulcer/s for Resident R2, R3 and R8. Review of clinical records also revealed that the facility did not provide treatment and services consistent with professional standards of practice to promote healing and prevent infection which resulted in worsening/deterioration of pressure ulcers for R1, R2, R3, R4, R6, R7, and R8. Interview with the DON, Director of Nursing, on May 6, 2025, at 11:30 a.m. stated facility hired a new wound care nurse Employee E8, in March of 2025, and she was responsible for completing wound rounds with the physician and…

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

Based on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with Enhanced Barrier Precautions for two of two residents reviewed ((Residents R1, and R2). Findings include: Review of literature revealed that Enhanced Barrier Precautions are infection control Intervention designed to reduce the transmission of novel or Multi-Drug-Resistant Organisms. Enhanced Barrier Precautions require to employ the use of targeted personal protective equipment (PPE) during high contact patient/resident activities. On February 20, 2025, at 10:00 a.m., review of physician order for Resident R1 revealed an order dated February 1, 2025, for Enhanced Barrier Precautions. Observation on February 20, 2025, at 10:04 a.m., revealed that a Licensed Nurse, Employee E3, and a Nurse aide, Employee E4 were hygiene care to Resident R1. Employees E3 and E4 did not wear the PPE, even though Resident R1 was on Enhanced Barrier Precautions. At…

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

Based on review of clinical record and review of facility provided documentation, it was determined facility did not ensure to complete a care plan that was comprehensive and individualized for one of five residents reviewed related to anxiety (Resident R1) Findings include: Review of facility policy 'Care Plans,' indicates that each resident's comprehensive care plan has been designed to: incorporate identified problem areas; reflect treatment goals and objectives in measurable outcomes; identify the professional services that are responsible for each element of care. Review of Resident R1's clinical record revealed that the resident had a medical history of anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, gastrostomy status, end stage renal disease, and cognitive communication disorder. Review of Resident R1's fall incident report, completed on December 24, 2024, revealed that the root cause analysis was that Resident R1 removed trach and became hypoxic due to confusion and agitation. Review of R1's nursing progress notes, dated November 23, 2024 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies and documents, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to enhanced barrier precautions for three of eight of infection surveillance, water management, infection data reporting and infection committee meetings, as required. (Resident 22, Resident 24 and Resident 19) Findings include: Review of facility policy, Infection Prevention and Control Manual dated June 13, 2024, revealed that the Infection Control Committee has the authority to implement effective measures for the detection, surveillance, control and prevention of healthcare associated infections. Infection Committee meetings are scheduled quarterly and the Committee recommends actions based on evaluation of the surveillance records and reports of infections. Continued review revealed that all healthcare associated infections that meet the McGeers criteria (used to assess infections) will be…

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

Based on review of personnel files, facility documentation and interviews with staff, it was determined that the facility failed to ensure that an effective training program was maintained as required for nine of 13 staff reviewed (Employees E22, E10, E23, E24, E28, E29, E30, E31 and E32). Findings include: Review of the Facility Assessment, dated last reviewed September 2024, revealed that the facility evaluates annually the educational needs including competencies that are needed for our staff. During this evaluation, the facility produces a list of educations and competencies that are needed annually. Continued review revealed, The facility holds a structured orientation for new hires. During this orientation the staff receive education and competencies on the necessary requirements. Further review of the Facility Assessment revealed that there was no indication of the specific trainings required for staff to meet the needs of the resident population. Review of Employee E22's personnel file revealed that the employee was hired by the facility on August 14, 2024, as a registered…

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

Based on observation and interviews with residents and staff, it was determined that the facility failed to maintain or enhance the dignity and respect related to dining for one of one nursing unit. (Nursing Unit rooms 701-738) Findings include: Observation on October 1, 2024, at 12:00 p.m. revealed lunch carts delivered to the nursing unit (rooms 701-738) and then lunch delivered to residents in their rooms. The lunch trays were observed as being served on Styrofoam plates and plastic utensils. Observation on October 2, 2024, at 12:10 p.m. revealed lunch carts delivered to the nursing unit (rooms 701-738) and then delivered to the residents in their rooms. The lunch trays were observed as being served on Styrofoam plates and plastic utensils. Interview with resident R21 on October 2, 2024, at 12:25p.m. revealed that he sometimes receives plastic utensils and sometimes receives regular utensils and he would prefer regular dinnerware, the plastic is difficult to use. Interview with Employee E12, Registered Dietician, on October 2, 2024, at 01:30 p.m. revealed that she was unaware…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, clinical record reviews and interviews with staff, it was determined that the facility failed to develop comprehensive care plans related to substance use disorder, pain management, dialysis access, mental health needs and enteral feeding needs for four of 14 residents reviewed (Residents R203, R7, R28 and R26). Findings include: Review of policy titled Care Plans revealed that the disciplinary team in coordination with the resident, his or her family representative, develops and maintains a care plan for each resident that identifies the highest level of functioning the resident may be expected to attain to our team. All care plans have been designed to identify problem areas incorporate risk factors associated with identified problems build on the resident strengths reflect treatment goals and objectives immeasurable outcomes identify the professional standards that are responsible for each element of care aid in preventing or reducing decline in residence…

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

Based on observations, clinical record review, review of facility documents and staff interviews, it was determined that the facility failed to revise the care plan for nutrition, mobility, and skin integrity, for three of 14 residents reviewed (Residents R1, R12 and R39). Findings include: Review of Resident R1's clinical record revealed that the resident was admitted in the facility on July 12, 2024. Resident R1's diagnoses included: Anemia (Anemia is a blood disorder that happens when an individual don't have enough red blood cells or the red blood cells don't work as they should). Cerebral Palsy (a group of neurological disorders that affect a person's ability to move, balance, and maintain posture. It's caused by damage to or abnormal development of the brain during a person's infancy or early childhood), Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and Respiratory Failure (Respiratory failure is a serious condition that occurs when the lungs can't get enough…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with staff, it was determined that the facility failed to follow physician orders related to blood pressure medications for one of 14 residents reviewed (Resident R7). Findings include: Review of Resident R7's Annual MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated September 4, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including heart failure (a chronic condition in which the heart doesn't pump blood as well as it should) and end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Review of physician orders for Resident R7 revealed on order, dated June 6, 2024, for midodrine 5 milligrams, give one tablet by mouth two times per day (9:00 and 9:00 p.m.) for hypotension (low blood pressure), hold for systolic blood pressure (SBP)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to provide care and assessments consistent with professional standards of practice related to intravenous therapy for three of three residents reviewed (Residents R43, R44, and R150 ). Findings include: Review of facility policy, Central Vascular Access Device (CVAD) Dressing Change dated January 17, 2019, revealed that CVADs include peripherally inserted central catheters (PICC) and subclavian catheters (catheter inserted into the vein near the collar bone). Continued review revealed that dressing changes are performed 24 hours post-insertion or upon admission and at least weekly. Continued review revealed that assessment of the CVAD is performed upon admission, during dressing changes, before and after administration of intermittent infusions and at least once every shift when not in use. Further review revealed that assessment of the arm with the CVAD includes, but…

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 personnel files and interviews with staff, it was determined that the facility failed ensure that nursing staff had specific competencies and skills sets necessary to care for residents' needs for seven of 13 personnel files reviewed (Employees E22, E10, E23, E24, E4, E25 and E26). Findings include: Review of the facility's Resident Matrix, dated October 4, 2024, revealed that 40 residents required tracheostomy (a surgically created hole in your trachea that allows for breathing) care, 22 residents required ventilator (machines that act as bellows to move air in and out of the lungs) care, three residents required intravenous therapy and two residents had physical restraints. Review of Employee E22's personnel file revealed that the employee was hired by the facility on August 14, 2024, as a registered nurse. Continued review revealed that there was no indication that the employee was evaluated or received skill competency training related to restraints, tracheostomies, ventilators, airway suctioning, oxygen administration, emergency airway management or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with staff, it was determined that the facility to ensure that the consultant pharmacist medication reviews were completed and that recommendations were reviewed by the physician in a timely manner for three of eight residents reviewed for medication regime reviews (Residents R38, R26, R7). Findings include: Review of Resident R38's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 16, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), respiratory failure (not enough oxygen passes from your lungs to your blood), anxiety disorder (intense, excessive, persistent worry or fear), tracheostomy (a surgically created hole in your trachea that allows for breathing)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that a resident was free from unnecessary medications, including the proper use and monitoring of medications, for one of 14 residents reviewed (Resident R45). Findings include: Review of Resident R45's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated September 12, 2024, revealed that the resident was admitted to the facility on [DATE], was in a persistent vegetative state and had diagnoses including hypertension (high blood pressure), seizures (abnormal electrical activity in the brain), anoxic brain damage (brain damage caused by lack of oxygen to the brain) and dependence on ventilator (machines that act as bellows to move air in and out of the lungs). Review of Resident R45's Medication Administration Records (MARs) for September 2024, revealed a physician's order, dated September 6, 2024, for morphine sulfate solution 20 mg (milligrams) per mL (milliliter),…

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 and documentation, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to maintain an effective antibiotic stewardship program for two of three of residents reviewed for antibiotics (Residents R38 and R26). Findings include: Review of facility policy, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes undated, revealed, Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance form. Continued review revealed that the Infection Preventionist will review all antibiotic starts within 48 hours to determined if continued therapy is justified, justified with needed intervention, or not justified. Further review revealed, At the conclusion of the review, the provider will be notified of the review findings and recommendations. His or her response will be documented. Review of Medication Administration Records (MARs) for Resident R26 revealed a physician's order, dated September 18, 2024, for Cefpodoxime…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with staff, it was determined that the facility failed to offer influenza and pneumococcal vaccines for five of five residents reviewed for vaccinations (Residents R43, R38, R2, R44 and R12). Findings include: Review of facility policy, Pneumococcal/COVID Vaccine Guidelines dated September 1, 2024, revealed, All residents will be offered the pneumococcal and COVID vaccines to aid in preventing pneumococcal and COVID infections. Continued review revealed, Each resident or the resident's authorized representative will receive education regarding the benefits and potential side effects of the vaccine. Review of facility policy, Influenza Vaccine undated, revealed that all residents will be offered the influenza vaccine annually. Continued review revealed, The facility shall provide pertinent information about the significant risks and benefits of vaccines to . residents. Clinical record review for Resident R43 revealed that the resident 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 personnel files and interviews with staff, it was determined that the facility failed to ensure that nurse aides received at least 12 hours of continuing education per year as required for three of five nurse aide personnel files reviewed (Employees E28, E31 and E32). Findings include: Review of Employee E28's personnel file revealed that the employee was hired by the facility on August 28, 2018, as a nurse aide. Review of Employee E31's personnel file revealed that the employee was hired by the facility on June 10, 2021, as a nurse aide. Review of Employee E32's personnel file revealed that the employee was hired by the facility on August 10, 2022, as a nurse aide. Further review of personnel files for Employees E28, E31 and E32 revealed that there was no evidence that the employees completed at least 12 hours of continuing education per year as required. Interview on October 4, 2024, at 6:54 p.m. the Nursing Home Administrator revealed that there were no continuing education records for Employees E28, E31 and E32 available for review at the time of the survey.…

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

Based on interviews with resident and staff, review of facility policy, and staff interview, it was determined that the facility failed to ensure that visitors were able to visit residents at all times for one of one resident reviewed. (Resident R203) Findings include: Review a facility policy titled Visitation revealed that the facility permits residents to receive visitors subject to the residents wishes and the protection of the rights of other residents in the facility. The resident's immediate family or other relatives may visit the resident at any time subject to the protection of the rights and safety of other residents. The visiting hours for non-family members are from 10:00 a.m. to 7:30p.m. daily or as designated by the administrator. CMS issued guidance to the previously released QSO-NH-20-39 issued on September 17, 2020, and revised on November 12, 2021, regarding visitation in nursing homes. This revised guidance stated that Visitation is now allowed for all residents at all times This was to be imposed immediately by nursing home facilities. Review of resident'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 observation, clinical record review, and review of facility policy and staff interview, it was determined that the facility did not ensure that the resident's privacy, regarding medical records were protected for one of seven residents observed. (Resident R13) Findings include: Policy title Uses and Disclosures of Protected Health Information dated August 2024 revealed that the purpose of this policy is to ensure building uses and disclosures of protected health information are in compliance with applicable law and appropriate safeguards are in place to ensure the confidentiality of the client protected health information (PHI). Staff are to minimize all areas where residents' names may be seen with their health information such as a turn paper over with names on it or clues or minimized screen with residents names on them. Review of the United Stated Department of Health and Human Services Health Insurance Portability and Accountability Act, https://www.hhs.gov/hipaa/for-professionals, revealed 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 observations, clinical record reviews and interviews with staff, it was determined that the facility failed to obtain consent, assess, monitor and re-evaluate hand mitts for one of two residents reviewed for restraints (Resident R150). Findings include: Observation, on October 1, 2024, at 10:46 a.m. revealed that Resident R150 was in bed, restless, and had a hand mitt (device that restricts the hands from being able to grab or hold) on her right hand. Interview, at the time of the observation, Employee E7, licensed nurse, revealed that Resident R150 required the use of hand mitts due to pulling at her tracheostomy and ventilator tubing. Continued observation, on October 1, 2024, at 1:53 p.m. revealed that Resident R150 was asleep comfortably in bed and had hand mitts on both of her hands. Continued observation, on October 2, 2024, at 10:29 a.m. revealed that Resident R150 was asleep comfortably in bed and had hand mitts on both of her hands. Continued observation, on October 3, 2024, at 9:10 a.m.…

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

Based on review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to complete a thorough investigation to rule out neglect related to a fall incident for one of four residents reviewed (Resident R50). Findings Include: Review of facility policy Abuse revealed the policy is intended to provide guidance on investigating and reporting suspected abuse, neglect, and misappropriation of resident property. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Further review of the facility policy revealed that all reports of abuse, neglect, and injuries of unknown origin shall be promptly and thoroughly investigated by the facility's Administrator. All reports of accidents or incidents involving a resident will be promptly reported and thoroughly investigated by the Administrator, the Director…

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

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for two of six residents reviewed (Residents R26, and R7). Findings include: Clinical record review for Resident R26 revealed a nurse's note, dated June 5, 2024, at 12:25 p.m. which indicated that the resident had abnormal labs, and was transferred to a local hospital for a blood transfusion. Continued clinical record review for Resident R26 revealed a nurse's note, dated June 25, 2024, at 1:06 p.m. which indicated that the resident had low oxygen levels. The physician was notified and ordered for the resident to be transferred to a local hospital for evaluation. Clinical record review for Resident R7 revealed a nurse's note, dated May 5, 2024, at 10:05 p.m. which indicated that the resident was found on the floor and had a hematoma (collection of blood due to injury or trauma) on her head. The physician was notified and ordered for the resident to be transferred to a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with staff, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for two of two residents reviewed related to PASRR assessments (Residents R28 and R7)). Findings include: The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level 1 PASRR determined that the person is a targeted person with mental illness or an intellectual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical records reviews and interviews with staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of admission that includes the instructions needed to provide effective and person-centered care, related to respiratory and enteral feeding needs for one of 14 residents reviewed (Resident R150). Findings include: Observation, on October 1, 2024, at 10:46 a.m. revealed Resident R150 lying in bed. The resident had a tracheostomy (a surgically created hole in your trachea that allows for breathing) and ventilator (machines that act as bellows to move air in and out of the lungs) that were assisting the resident to breath. Continued observation revealed that the resident received a nutritional feeding formula via a pump connected to her gastronomy tube (a surgical opening and placement of a tube though a person's abdominal wall into their stomach). Review of Resident R150's care plan revealed that she was admitted to the facility on [DATE], and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, review of facility documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that the resident and their representatives were involved in an effective discharge planning process for one of three residents reviewed. (Resident R49) Findings include: Review of facility policy titled Discharging a Resident Against Medical Advice revealed that should a resident request immediate discharge the residents attending physician must be promptly notified as the residents representative have the right to make decisions for their own care should they resident request discharge from the facility. Review of the facility document [NAME] of Rights under the heading Discharges and Transfers given to all residents at time of admission revealed to discharge yourself from the nursing home the resident must present a signed release signed the resident or the resident's guardian. Review of Resident R49's Minimum Data Set (MDS- a federal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide adequate monitoring to prevent complications related to enteral feeding for two of four residents reviewed for tube feedings (Residents R150 and R26). Findings include: Observation, on October 1, 2024, at 10:46 a.m. revealed Resident R150 lying in bed and receiving a nutritional feeding formula via a pump connected to her gastronomy tube (a surgical opening and placement of a tube though a person's abdominal wall into their stomach). Review of Resident R150's care plan revealed that she was admitted to the facility on [DATE], and had diagnoses including gastrostomy and anoxic brain damage (brain damage caused by lack of oxygen to the brain). Review of physicians' orders for Resident R150 revealed an order, dated September 21, 2024, to obtain weight at admission and then weekly weights time four weeks for a total of five weeks. Review of weights for Resident R150 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents received dialysis services consistent with professional standards of practice related to fluid restrictions and dialysis access for one of one residents reviewed who received dialysis services (Resident R7). Findings include: Review of the facility's affiliation agreement with a contracted dialysis agency, dated September 1, 2018, revealed that the facility will notify the dialysis facility when a dialysis resident refuses scheduled medical management or demonstrates non-compliance with medical management related to renal replacement therapy, i.e., diet, fluid restriction, and medications. Review of Resident R7's Annual MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated September 4, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including heart failure (a chronic condition in which…

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 documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to provide routine medications to meet residents' needs for two of 14 residents reviewed (Residents R45 and R22). Findings include: Review of Resident R45's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated September 12, 2024, revealed that the resident was admitted to the facility on [DATE], was in a persistent vegetative state and had diagnoses including hypertension (high blood pressure), seizures (abnormal electrical activity in the brain), anoxic brain damage (brain damage caused by lack of oxygen to the brain) and dependence on ventilator (machines that act as bellows to move air in and out of the lungs). Review of Medication Administration Records (MARs) for Resident R45 revealed a physician's order, dated September 19, 2024, for fluconazole (medication used to treat fungal infections) administer one tablet once per day for seven…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed ensure that residents were free from unnecessary psychotropic medications, including the proper use and monitoring of medications, use of as needed medications are limited to 14 days and receiving gradual dose reductions, for two of 14 residents reviewed (Residents R45 and R3). Findings include: Review of facility policy, Psychotropic Medications undated, revealed, Psychotropic medications are drugs that affect brain activities with mental processes and behaviors. Continued review revealed, GDRs [Gradual Dose Reductions] and behavioral interventions will apply for all psychotropics. Further review revealed, PRN [as needed] psychotropic medications are limited to fourteen (14) days . If the prescriber wants the PRN order to be extended, then he/she must document rationale in medical record [and] indicate the duration of the PRN order. Review of Resident R3's clinical record revealed…

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

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of four residents observed during medication administration (Resident R7). Findings include: On October 2, 2024, at 9:49 a.m., observed that Employee E4, a Licensed Nurse, administered to Resident R7, the medicine, Vitamin B Complex, (which has no Vitamin C) tablet. Review of physician order dated June 2, 2024, for Resident R7, revealed an order to administer Nephro-Vite Rx Oral Tablet 1 MG (B-Complex with C & Folic Acid), Give 1 tablet by mouth in the morning for Renal Deficiency. At the time of the observation, interview with Licensed Nurse, E4, confirmed the above findings. On October 2, 2024, at 9:49 a.m., observed that Employee E4, a Licensed Nurse, administered to Resident R7, 5 ml of Ferrous Sulfate Syrup 220 MG/5ML (which equals 220 MG). Review of physician order dated June 2, 2024, for Resident R7, revealed an order to administer Ferrous Sulfate Syrup 300 (60…

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

Based on review of clinical records and interview with residents and staff it was determined that the facility failed to routinely offer evening snacks as desired by two of two oriented residents (R21 and R7). Findings include: Review of facility policy titles Mealtimes revealed that the facility provides mealtime is breakfast is served between 8:15 a.m. and 8:30 a.m., lunch is served between 12:15 p.m. and 12:30p.m. and dinner is served between 4:45 p.m. and 5:15 p.m. Interview was held on October 2, 2024 at 1:10p.m. with Resident R21 revealed that snacks were not routinely offered in the evenings and that they would like to receive an evening snack. Interview with Employee E 12 revealed that snacks are always available for all residents and some residents have orders for snacks. Interview on October 1, 2024, at 11:17 a.m. Resident R7 stated that she likes eating snacks, that her family has to bring them in for her because the facility only offers snacks every once in a while and that the facility does not offer her any snacks at bedtime. Observation, at the time of the interview,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with staff, it was determined that the facility failed to offer COVID vaccines for three of five residents reviewed for vaccinations (Residents R43, R38 and R44). Findings include: Review of facility policy, Pneumococcal/COVID Vaccine Guidelines dated September 1, 2024, revealed, All residents will be offered the pneumococcal and COVID vaccines to aid in preventing pneumococcal and COVID infections. Continued review revealed, Each resident or the resident's authorized representative will receive education regarding the benefits and potential side effects of the vaccine. Clinical record review for Resident R43 revealed that the resident was admitted to the facility on [DATE]. Continued review revealed that there was no indication in Resident R43's clinical record that the resident was offered the COVID vaccine. Clinical record review for Resident R38 revealed that the resident was admitted to the facility on [DATE]. Continued review revealed that there was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to provide assistance with repositioning for three of three residents who were dependent on assistance with activities of daily living (Residents R1, R2 and R3). Findings include: Review of facility policy, Prevention of Pressure Ulcers undated, revealed that for residents who are bed-fast (unable to get out of bed) change positions at least every two hours and more frequently as need. Review of Resident R1's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated May 9, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including stroke (damage to the brain from interruption of its blood supply), intracranial hemorrhage (bleeding in the brain), hydrocephalus (a build-up of fluid in the brain) and respiratory failure (not enough oxygen passes from your lungs to your blood). Continued review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to provide care and assessments consistent with professional standards of practice related to intravenous therapy for three of three residents reviewed (Residents R1, R2 and R3). Findings include: Review of facility policy, Central Vascular Access Device (CVAD) Dressing Change dated January 17, 2019, revealed that CVADs include peripherally inserted central catheters (PICC) and subclavian catheters (catheter inserted into the vein near the collar bone). Continued review revealed that dressing changes are performed 24 hours post-insertion or upon admission and at least weekly. Continued review revealed that assessment of the CVAD is performed upon admission, during dressing changes, before and after administration of intermittent infusions and at least once every shift when not in use. Further review revealed that assessment of the arm with the CVAD includes, but is not…

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, review of facility investigation and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation to rule out neglect related to a resident who was assessed with high glucose levels and was not emergently transfer to a hospital for one of one resident reviewed. (Resident CL1). Findings include: Review of Resident CL1's clinical record reveled that Resident CL1 was admitted to the facility on [DATE], with diagnosis of Diabetes Mellitus (DM-a chronic condition that affects the way the body processes blood sugar (glucose). Review of Resident CL1's nursing note revealed a nursing entry dated [DATE], at 8:06 p.m. nurse called on call physician again to inform that the Resident CL1's blood sugar remained elevated. The on-call physician stated to stop the Dextrose 5 percent and give her an additional 30 units of regular insulin and to recheck in an hour. Review of Resident CL1's nursing note written by Registered nurse, Employee…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility resulting in an Immediate Jeopardy situation related to a resident who was assessed with high glucose levels and was not emergently transfer to a hospital for one of one resident reviewed. (Resident CL1) Findings include: Review of the job description of the Nursing Home Administrator (NHA) revealed that the primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be always provided to our residents at all times. As the Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Develop and maintain written…

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 interview with staff, it was determined that the facility did not maintain complete documentation related to blood sugar levels obtained for three of six clinical records reviewed. (Resident R1, R2, & R3). Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], and had diagnoses of type 2 diabetes mellitus without complication. Further review of the resident's record revealed a physician orders obtained on July 30, 2024, inject 12 unit subcutaneously at bedtime for DM. Inject as per sliding scale: if 70 - 150 = 0; 151 - 200 = 1; 201 - 250 = 2; 251 - 300 = 3; 301 - 350 = 4; 351 - 400 = 5, subcutaneously every 6 hours for DM call MD if BS < 70 or > 400 Review of Resident R1's medication administration record and progress notes for the month of July 2024 revealed that there was no documentation for blood sugar level obtained on July 21, 2024, at 12:30 pm. Review of Resident R2's clinical record revealed that 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 observations, clinical record review and interviews with staff, it was determined that the facility failed to ensure that resident assessments accurately reflected residents' status related to restraints for one of two residents reviewed on restraints (Resident R36). Findings include: Observation, on December 18, 2023, at 11:30 a.m. revealed that Resident R36 was wearing hand mitts (a type of physical restraint) on both of his hands. Continued observation, on December 19, 2023, at 12:29 p.m. revealed that Resident R36 continued to wear hand mitts on both of his hands. Review of Resident R36's care plan, dated initiated May 16, 2022, revealed that the resident used physical restraints bilateral hand mitts secondary to pulling at tracheostomy (a surgically created hole in your trachea that allows for breathing) and tubing putting self at high risk for decannulation (removal of tracheostomy tube) related to confusion. Review of Resident R36's physician orders revealed that the resident had ongoing orders for the bilateral hand mitts from May 16, 2022, through December 19,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review and interviews with staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of a resident's admission related to ventilators for two of three residents with ventilators reviewed (Resident R1 and Resident R97). Findings include: Observation, on December 18, 2023, at 11:24 a.m. revealed that Resident R97 was connected to a ventilator (machines that act as bellows to move air in and out of the lungs) to help him breathe. Continued observation, on December 19, 2023, at 12:29 p.m. revealed that Resident R97 continued to use a ventilator. Review of progress notes for Resident R97 revealed a respiratory note, dated December 4, 2023, at 5:29 p.m. which indicated that the resident was a new admission, and that upon his arrival to the facility the resident was placed on a ventilator. Continued review of progress notes for Resident R97 revealed a pulmonary (branch of medicine specializing in lung and breathing disorders) 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 policies, clinical record reviews and interviews with staff, it was determined that the facility failed to adequately monitor the nutritional and hydration status for one of two residents reviewed related to nutrition (Resident R1). Findings include: Review of facility policy, Significant Weight Gain dated 2019, revealed that, Appropriate members of the interdisciplinary team (IDT) will: Identify individuals with significant weight gain . reweigh to assure accurate weight . assess for recent weight loss . consider food intake . [and] assess for possible fluid imbalances. Continued review revealed that Significant Weight Gain is considered as five percent gain in one month and that Severe Weight Gain is considered as greater than five percent gain in one month. Review of Resident R1's admission MDS assessment (Minimum Data Set - a mandatory periodic resident assessment tool), dated September 26, 2023, revealed that the resident was admitted to the facility September 19, 2023, and had diagnoses including end stage renal disease (a medical condition in which…

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

Based on observations, review of facility policy and interview with staff, it was determined that the facility failed to ensure that physican orders were followed related to one of seven residents reviewed with a gastrostomy tube. (Resident R31) Findings include: Review of facility's 'Tube feeding/Enteral nutrition' policy, effective 2020, states the following: 6. Tube placement will be checked each shift prior to each feeding, flush or medication pass. 7. The licensed nurse will not check residuals routinely. A residual should only be checked if the patient presents with signs/symptoms not tolerating enteral feedings, for example: nausea, vomiting, abdominal distention, discomfort, fullness, or bloating. 8. Check residual prior to feeding or with med pass > 250ml hold feeding for 1 hour and recheck, if still > 250 ml contact MD and document. 9. The licensed nurse will assess the following prior to initiating the tube feeding: security of the tube and the appearance of the insertion site. Review of Resident R31's psych evaluation dated November 17, 2023, revealed history of cardiac…

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

Based on review of personnel records and interviews with staff, it was determined that the facility failed to complete annual performance reviews for nurse aide staff as required for three of three nurse aide personnel files reviewed (Employees E11, E12 and E13). Findings include: Review of Employee E11's personnel filed revealed that she was hired by the facility on August 20, 2018, as a nurse aide. Continued review revealed than an annual performance review had not been completed for the employee. Review of Employee E12's personnel filed revealed that she was hired by the facility on August 24, 2022, as a nurse aide. Continued review revealed than an annual performance review had not been completed for the employee. Review of Employee E13's personnel filed revealed that she was hired by the facility on October 18, 2021, as a nurse aide. Continued review revealed than an annual performance review had not been completed for the employee. Interview on December 19, 2023, the Nursing Home Administrator stated that no annual performance reviews had been completed for any nursing staff.…

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 interviews with staff, it was determined that the facility failed to develop and implement a person-centered baseline care plan for skin care and treatment for one of three residents reviewed. (Resident R1) Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE]. Review of the nursing assessment dated [DATE] indicated that this resident was incontinent of bowel and bladder. The resident had a colostomy (an operation that creates an opening for the colon through the abdomen) and required nursing care for the use of a colostomy collection bag and supplies. This nursing note also indicated that Resident R1 was admitted with a deep tissue injury (a pressure injury to subcutaneous tissue under intact skin) of the left foot. On August 12, 2023 the nursing note for Resident R1 indicated that this resident had an opened skin area around the colostomy stoma. The nursing note also indicated that the area was cleansed…

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.