Caring Heart Rehabilitation And Nursing Center

Based on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of 38 residents reviewed (R191). Findings include: Review of the facility policy and guidelines for implementation of oxygen administration indicated that the nurse should review and follow the physician's orders while administering oxygen via nasal canula. Review of clinical records revealed that Resident R191 was admitted in the facility on July 9, 2024. R191 had diagnoses that included Chronic Obstructive Pulmonary Disease ( (COPD), and Pulmonary Hypertension due to Lung Disease and Hypoxia (Pulmonary hypertension (PH) due to lung disease and hypoxia is a condition where high blood pressure develops in the pulmonary arteries (blood vessels in the lungs) as a result of lung damage and/or low blood oxygen levels (hypoxia). This high blood pressure makes it harder for the heart to pump blood through the lungs, potentially leading to right heart failure). Review of physician 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 observation, interview with staff, clinical record review and reviews of facility policy, it was determined that the facility failed to ensure complete communication between the facility and the dialysis care provider for two of three residents reviewed. (Residents R8 and R539) Findings include: Review of facility policy titled Dialysis revised October 1, 2024, revealed that the facility will provide the necessary care and treatment, consistent with professional standards of practice . the comprehensive person-centered care plan and the residence goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. Continued review of this policy revealed that a licensed nurse will communicate to the dialysis facility via telephone communication or written format such as the dialysis communication form that will include but not limited to physician laboratory values and vital signs and changes or decline in condition on related to dialysis. Review of facility dialysis long term care facility agreement with renal…

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 clincial record review and staff interview, it was determined that the faciltiy failed to ensure that a plan of care and assessment was completed for one of one resident with a diagnosis of post traumatic stress disorder (PTSD) . (Resident R50) Findings include: Review of facility policy title Trauma Informed Care dated October 2nd, 2022, revealed it is the policy of the facility to provide care and services are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and or traumatization. Ensuring the residents choice and preferences are honor and the residents are empowered to be active participants in their care. An emphasis on partnering between residents, representative, and all staff and disciplines involved in the residence care in developing the plan of care. The facility will identify triggers which may be traumatized residents with a history of trauma, and update care plans to include interventions provided by the resident, family members, mental health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and review of resident records, it was determined the facility failed to maintain complete and accurate records for restorative therapy for one of 38 resident records reviewed (Resident R162) Findings include: Review of Resident R162's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of osteoarthritis (degeneration of joint cartilage), dementia ( a progressive cognitive disease with a loss of daily functions), abnormalities of gait and mobility. Review of Resident R162 's care meeting notes dated, February 4, 2025, indicated the resident was currently on physical therapy able to walk 180 feet using a rolling walker with one person assisting. Review of Resident R162's therapy Discharge summary dated , February 10, 2025, recommended the restorative nursing program (RNP) to facilitate the resident maintaining current level of performance and in order to prevent decline. The same discharge summary indicated the development of and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, review of the clinical record and facility documentation, it was determined that the facility failed to ensure that a communication process was utilized for communication between the facility and the hospice care agencies for one out of three residents review receiving hospice care (Resident R204). Findings Include: Review of the facility's policy titled, Hospice with a revision date on October 1, 2024 states, Policy: When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being. Further review of the facility policy revealed, Guidelines: 1. The facility maintains written agreements with hospice providers that specify the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding the resident's care. 2. The facility and hospice…

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 of the food and nutrition services department, interviews with residents and staff, it was determined that essential equipment used to operate the food service was not being maintained in safe operating condition. Findings include: Observations of the main kitchen at 11:30 a.m., on June 9, 2025 revealed a tray line, steamtable and plating of foods. Observations of the main kitchen at 12:00 a.m., on June 9, 2025 revealed that the kitchen was not equipped with an operating plate warmer. The food service director, Employee E12 reported that the food service department was waiting for repairs for this essential piece of food service equipment to be fully operational. Observations of the main kitchen at 11:30 a.m., on June 10, 2025 revealed that the dinnerware (plates) did not fit inside the plate warmer and were stacked on top of each other two feet above the warming mechanisms of the plate warmer after being repaired. The plates were not warm or hot to touch. Interview with the food service director, Employee E12 at 11:30 a.m., on June 10, 2025 revealed that a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical record, facility documentation and staff interviews, it was determined that the facility failed to provide food that accommodates resident allergies, one of two residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses of Chronic Kidney Disease, Trisomy 21 (Down Syndrome) and Dementia. Further review of Resident R1's clinical record revealed that was Resident R1 was allergic to Apricots, Apricot Kernels and Corn. Review of copy of meal ticket dated October 7, 2024, revealed that the meal ticket was labelled with Resident R1's name. Further the meal ticket indicated: Allergies: Corn and Corn products. Under Main menu: chicken tenders with honey mustard sauce, Parslied Noodles, Honey Glazed Carrots, white roll. Further, in bold letter: No sub found for Apricots. At the bottom of the meal ticket, was written ALLERGY: Apricots, Corn. Interview with Regional Dietary…

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

Based on staff interview, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that a resident's responsible party had the right to be notified of the resident's change in treatment for one out of two residents reviewed (Resident R1). Findings include: Review of the facility's policy, Notification of Change in Condition, with a revision date of April 1, 2021 reported that the facility must inform the resident, consult with the resident' physician and/or notify the resident's family member or legal representative when there is a change requiring notification such as, but not limited to: accidents resulting in injury, significant change in the resident's physical mental or psychosocial condition, and circumstances that require a need to alter the resident's treatment (e.g. a new treatment of the discontinuation of a treatment). Review of the September 2024 physician orders indicated that the resident was admitted into the facility on August 16, 2024 with diagnosis that included the following: hypertension (high blood…

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

Based on staff and resident interview and review of clinical records, it was determined that the facility failed to ensure that advanced notice was provided for participation in a care plan meeting for one out of two resident's reviewed (Resident R1). Findings include: Review of the September 2024 physician orders indicated that the resident was admitted into the facility on August 16, 2024 with diagnosis that included the following: hypertension (high blood pressure); dementia (a group of symptoms affecting an individual's memory, thinking and social abilities); cerebral infarction (a stroke), and muscle weakness. Review of the resident admission Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) completed on August 18, 2024 indicated that the resident was cognitively impaired. During an interview with the resident's daughter on September 25, 2024 at 11:43 a.m. the resident's daughter reported that she reached out to the facility social worker (Employee E3) on August 25, 2024 to find out the date of her mother's care plan meeting and the process for care…

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

Based on staff interviews and the review of the clinical record, it was determined that the facility failed to ensure that notification was provided to a resident and his/her responsible party prior to a room change for one of two residents reviewed (Resident R1). Findings include: Review of the facility, Change or Room or Roommate dated January 2024 indicated that it is the facility's policy to conduct changes to room and/or roommate assignments when considered necessary and/or when requested by the resident or resident representative. The policy also indicated that request for room change, all persons involved in the change/assignment, such as residents and their representatives will be given advanced notice of such a change, as is possible and that the social services designee or licensed nurse should inform the resident's sponsor/family of the room change in advance of a change in the resident's room/roommate Continued review of the policy indicated that the notice of change in room of roommate will be provided in writing, in language manner the resident and representative…

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, staff interviews, and the review of clinical records, it was determined that the facility failed to ensure that a complete and through investigation was completed in a timely manner to rule out abuse/neglect for one out of three residents reviewed (Resident R1). Findings include: Review of the facility policy Abuse, revised November 20, 2020 indicated under the Identification section of the abuse policy that staff receives education about the behavioral and situational signals that may indicate risk for or the presence of abuse, neglect or misappropriate of property. The Identification section also included signs and symptoms of abuse that may possibly indicate presence of which attention will be given to, include, a resident having bruises, cuts, the appearance of dehydration, the appearance of feeling anxious, afraid, confused, depressed. The policy also highlighted that other signs and symptom that may possibly indicate the presence of abuse, that attention will be given to included someone in contact with the resident might neglect to provide the…

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

Based on review of facility policy, observations, and interviews with staff and residents, it was determined that the facility did not ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. Findings Include: Review of facility policy Food Storage undated revealed plastic containers with tight-fitting covers must be used for storing grain products. Leftover food will be stored in covered containers and wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 7 days or discarded. An initial tour of the Food Service Department conducted on August 5, 2024, at 9:42 a.m. with the Food Service Director, Employee E4, revealed the following: Dietary employees were observed using the dish machine to clean utensils, cups, plates, meal trays, and lids from the breakfast meal. Based on review of the dish washer water temperatures, the dish washer should have been using chemicals for proper sanitation. Observations of the operation of the dish machine with the…

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

Based on review of facility policy, review of facility documentation, observation, and staff interview it was determined that the facility failed to ensure that essential equipment was maintained in safe and operating conditions related to the dish machine in the main kitchen and handwashing sink in the laundry area. Findings Include: Review of facility policy Sanitation of Dishes/Dish Machine undated, revealed for a high temperature dish washer, wash temperature should be 150-165 degrees Fahrenheit, and final rinse temperature should be 180 degrees Fahrenheit. Further review of facility policy revealed for a low temperature dish washer the wash temperature should be 120 degrees Fahrenheit and the sanitation should reach at least 50 ppm (parts per million). An initial tour of the Food Service Department conducted on August 5, 2024, at 9:42 a.m. with the Food Service Director, Employee E4, revealed the following: Dietary employees were observed using the dish machine to clean utensils, cups, plates, meal trays, and lids from the breakfast meal. Interview with the Food Service…

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 residents were treated with dignity and respect related to the dining experience on one of four floors reviewed. (Third floor) Findings Include: Review of facility policy titled, The Person Centered Dining Approach undated states, Policy: Person centered care and hospitality services, including dining, will be a vital part of everyday living. The person centered dining approach will focus on each individual's needs related to food, nutrition, and dining. 8. Use of napkins will be encouraged, and dignified clothing protectors will be available as needed or requested. 11. Staff will sit next to a person when assisting them with eating (rather than standing over them. 13. Individuals at the same table will be served and assisted at the same time. Observation of the dining experience was held on August 5, 2024 at 12:21 p.m. on the third floor Cliveden unit. The lunch menu posted listed fish sticks, garden rice, parsley carrots, fruit crisp, and milk. 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 observation and staff and interviews iwth resident's representative, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for residents on one of six nursing units and 2nd floor patio. (3rd Floor Cliveden and 2nd floor patio) Findings include: Interview with Resident R103's family member on August 5, 2024, at 11:01 a.m. stated facility was not always clean, family member stated there is always trash on the floor of the shower room and clutter in the shower room. Observation of the first shower room of 3rd floor on August 5, 2024, at 11:07 a.m. with third floor unit manager revealed there was brown colored dried stain dripping on the wall, unit manager stated there was shower room at the same location on the top floor. The corner had a broken tiles which exposed the dry wall. The toilet seat had yellowish colored stain, the tissue box had dust on it, broken border, and the shower curtain had yellow stain. There was also broken/missing base board…

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 review, observations and staff interviews, it was determined the facility failed to identify beds against the wall as a possible restraint and failed to assess the functional status of individual residents to determine the use of the restraint for three of thirty-seven residents reviewed. (Residents R189, R25, and R218). Findings Include: Review of facility policy titled, Restraints with a revision date of December 2019 states, Policy: To foster the philosophy ., in compliance with Federal and State Regulations and in accordance with HIPPA Regulations, it is the policy of to provide residents with a restraint-free environment which promotes independence, safe freedom of movement, dignity and overall quality of life. Residents with functional deficits all receive appropriate therapeutic measures, including assistive devices. Procedure: 1. Initiation of restraint a. The resident will be assessed for the need of a restraint b. It will be discussed with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure comprehensive care plans were developed to address resident care needs for six of 37 residents reviewed (Residents R65, R189, R25, R218, R225, R40 ). Findings Include: Review of Resident R65's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 1, 2024, revealed the resident was cognitively intact. Review of Resident R65's comprehensive care plan dated August 31, 2023, revealed the resident was at risk for falls related to poor safety awareness, weakness, and deconditioning. Observation on August 8, 2024, at 10:00 a.m. revealed Resident R65 had her bed pushed against the wall and no bed rails on the bed. Interview on August 8, 2024, at 10:05 a.m. with Licensed Nurse, Employee E11, confirmed Resident R65 had her bed pushed up against the wall per the resident's preference. Review of Resident R65's comprehensive care plan 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 review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to monitor and modify interventions consistent with the resident's needs to maintain acceptable parameters of nutritional status for four of eight residents reviewed for nutrition (Resident R65, Resident R100, Resident R114, and Resident R69). Findings Include: Review of facility policy Nutrition effective December 2018 revealed resident weights will be obtained to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. The Dietitian/designee will reassess the nutritional needs and intakes of any resident with a significant weight changed as defined by the Minimum Data Set (MDS - federally mandated resident assessment and care screening). Interventions will be evaluated, documentation made in the electronic medical record, and the resident's plan of care updated. Further review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, observations, and staff and resident interviews, it was determined that the facility failed to ensure that menus were followed to meet the daily nutritional needs and preferences of the residents for six of six nursing units and three of 29 residents reviewed for dining observations (Resident R100, R114, and R76). Findings Include: Review of the facility menu extension sheets for the week of 08/05/2024 revealed milk is part of the menu and should be provided with breakfast, lunch, and dinner. Observation made of the lunch meal on August 5, 2024 at 12:05 p.m. on the third floor in the dining room. The lunch menu posted listed the following for the meal: fish sticks, garden rice, parsley carrots, fruit crisp, and milk. Review of 19 resident trays during the lunch meal revealed none of the residents were provided milk on their trays. Interview with nurse aide, Employee E15 at 12:40 p.m. revealed residents aren't always given milk on their trays. Employee E15 stated 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, and interviews with residents, it was determined that the facility failed to maintain an effective pest control program in the resident care areas for two resident rooms units reviewed. (Second floor and third floor) Findings include: Observation of Resident room [ROOM NUMBER] on August 5, 2024, at 10:52 a.m. revealed that there was flies in the room. Interview with Employee E22, House keeping staff confirmed the finding. Observation of the first-floor conference room on August 6, 2024, at 2: 30 p.m. with facility administration including Administrator and Director of Nursing reveal ed that there was flies in the room. Observation of facility second floor nursing area revealed that there were flies in the hall way. Review of the pest control log dated July 10, 2024 reevaled that there was flies reported in room [ROOM NUMBER]. Review of the pest control log dated July 16, 2024 reevaled that there was fruit flies reported on 5th floor Review of the pest control log dated July 21, 2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and review of facility policy, it was determined that the facility failed to notify resident representatives of a resident's change in condition related to dislodged nephrostomy tube for one of 37 residents reviewed. (Resident R378) Findings include: Review of facility policy on the nephrostomy and cystostomy tube care and maintenance revealed that under section Policy, residents with nephrostomy or cystostomy tubes will receive care consistent with professional standards of practice, the comprehensive person centered care plan, and the residents goals and preferences. Review of Resident R378's clinical record revealed that Resident R378 was admitted to the facility on [DATE], with diagnoses of but not limited to hypertension (high blood pressure), hyperlipidemia (high chlesterol), Malignant neoplasm of Bronchus and Lung, Diabetes Type 2, Acute Respiratory Failure, Alzheimer's Diseases (brain disorder that causes problems with memory, thinking and behavior). Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the minimum information necessary to properly care for a resident, for one of one resident reviewed related to substance abuse disorder (Resident R529). Findings include: Review of Resident R529's hospital record dated August 2, 2024, revealed that the resident had a history of polysubstance disorder (3 bundles of fentanyl daily, up to one bundle at a time and Xanax). Resident was started on Suboxone for drug addiction. Resident had severe wound with etiology related to drug use. Review of progress note for Resident R529 dated August 2, 2024, revealed that the resident was admitted to the facility on [DATE], with diagnosis of septic shock, opioid drug use, and depression. Review of Medication Administration Record for Resident R529 for August 2024 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of clinical records, facility policies, and interview with staff and residents, it was determined that the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Facility failed to update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities for two of four residents reviewed for discharge planning process. (Resident R144 and R226) Findings Include: Review of facility policy Discharge Planning: dated January 2019 revealed that To foster the Philosophy of Caring Heart Rehabilitation and Nursing Center, in compliance with Federal and State Regulations and in accordance with HIPAA Regulations, it is the Policy of Caring Heart…

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, review facility policies, and interview with staff, it was determined that the facility failed to ensure that a resident received necessary equipment to maintain resident's functional status in range of motion and mobility for one of 37 residents observed. (Resident R56) Finding: Review of Resident R56's clinical record revealed that Resident R56 was admitted to the facility on [DATE]. Further review of Resident R56' clinical record revealed that Resident R56 had the diagnoses of Aphasia related to Cerebrovascular Disease, Hemiplegia (weakness to one side of the body) Hemiparesis following Cerebral Infarction, General Weakness, Unspecified lack of Coordination. Review of Occupational Therapy discharge note dated April 1, 2024, revealed that prognosis was good with consistent staff followed-through. Further recommendation was Restorative Nursing Program to applied a right palm guard during the morning care and to remove it the right palm guard during p.m. care.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, facility policies and procedures, and interviews with staff and resident, it was determined that the facility failed to provide adequate treatment and care for a PICC (Peripherally Inserted Central Line Catheter) in accordance with professional standards of practice for one of one resident with PICC line reviewed (Resident R529). Findings include: Review of facility policy, Care of the Peripherally Inserted Central Catheter dated December 2023, revealed that Measure external PICC catheter on admission and note length with every dressing change. Place length as supplemental documentation in the order sign off. Transparent dressings must be labeled and changed every 7 days or more frequently (prn) if the dressing is damp, loose, soiled or if any damage occurs. Review of clinical record for Resident R13 revealed that the resident was admitted to the facility on [DATE]. Observation of Resident R529 on August 6, 2024, at 10:00 a.m., revealed that the resident had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and review of clinical records, it was determined that the facility failed to provide pharmaceutical services to assure the acquiring and administering of medications to meet the needs of each resident for one of 37 residents reviewed (Resident R100). Findings Include: Review of facility policy Unavailable Medications revised December 2023 revealed staff shall take immediate action when it is known that a medication is unavailable and determine reason for unavailability, length of time med is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication. Staff should notify the physician when a medication is unavailable. Staff should further obtain alternative treatment orders and/or specific orders for monitoring resident while the medication is on hold. Review of Resident R100's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 13, 2024, revealed the resident was admitted…

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 two of six residents observed during medication administration. (Resident R135 and Resident R6) Findings include: On August 6, 2024, 9:11 a.m., observed that Employee E7, a Licensed Nurse, administered to Resident R135, the medicine, Fluticasone Propionate Nasal Suspension 50 MCG/ACT, one spray to each nostril. Review of physician order for Resident R135, dated May 20, 2024, revealed an order to administer Fluticasone Propionate Nasal Suspension 50 MCG/ACT, two sprays to alternating nostrils, one time a day for asthma. At the time of the observation, interviewed with Licensed nurse Employee E7, confirmed the above findings. On August 6, 2024, 9:11 a.m., observed that Licensed nurse, Employee E7, did not administer to Resident R135, the physician ordered buPROPion HCl Oral Tablet 75 MG (Bupropion HCl), Give 37.5 mg by mouth one time a day after breakfast. Employee E7 stated…

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, review of facility policy, observation, and staff and resident interview, it was determined that the facility failed to ensure that all drugs and biologicals were stored in accordance with professional standards for one of four floors reviewed (fourth floor) and two of 37 residents reviewed (Resident R379 and Resident R528). Findings include: Observation of the Resident R528's room conducted on August 5, 2024, at 10:32 am during the tour of the 2nd floor revealed a medication cup on top of Resident R528's breakfast tray. There were six pills in the cup. Interview with Resident R528's son on August 5, 2024, at 10:32 am stated the medication cup with medication was on top the bed near the foot of the bed when he came in the morning, he stated he took it and placed it in the breakfast tray so that the resident would not spill it. Interview with Employee E23 on August 5, 2024, at 10:35 a.m. stated resident was not supposed to self-administer the medication and the medications was not the morning medications she administered, it may be from previous…

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 resident interviews, it was determined that the facility failed to submit complete and accurate information to the State Survey Agnecy regarding a resident fall and subsequent transfer to the hospital for one of six residents reviewed for falls incidents (Resident R65). Findings Include: Review of Resident R65's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 1, 2024, revealed the resident was cognitively intact. Review of facility reported documentation submitted to the Department of Health on April 8, 2024, revealed that on April 8, 2024, Resident R65, had a fall in her room and sustained an open area to the forehead. Continued review of the facility reported documentation revealed safety measures were in place at the time of the fall. Resident R65 was transferred to the hospital for evaluation and returned. Per the facility reported documentation, the hospital computed tomography (CT - imaging test that helps healthcare providers detect injuries) scan…

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 interviews with staff, it was determined that the facility failed to ensure that medication administration records were complete for one of five residents reviewed. (Resident R2) (Resident R2 ) Findings include: A review of Resident R2's March 2024 physician orders revealed orders for Atorvastatin (40mg) to be administered daily for high cholesterol; Diazepam (2mg) to be administered daily for anxiety; Hydroxychloroquine (200mg) an antiviral agent to be administered daily to treat an infection; and Pantoprazole (40mg) to be administered daily to treat gastroesophageal reflux disease (GERD). A review of the medication administration record (MAR) for resident R2 dated March 2024 revealed the following: no documentation in the MAR that resident R2 had received the scheduled dose of atorvastatin on March 20, 2024; no documentation in the MAR that resident R2 had received the scheduled doses of diazepam on March 16, 17, and 20, 2024; no documentation in the MAR that resident R2 had received the scheduled dose of Hydroxychloroquine on March 20,…

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, and interviews with staff, it was determined that the facility failed to maintain a clean, comfortable, and homelike environment for three of three floors reviewed. (Second floor, Third floor, Fifth Floor) Findings Include: Review of the facility policy titled, Routine Cleaning and Disinfection undated states, Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Policy Explanation and Compliance Guidelines: 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge. 2. Staff will look for precautions signage prior to entering resident's room. 3. Cleaning considerations include, but are not limited to, the following: a. Dry clean procedures will be conducted before wet…

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

Based on observation, review of facility policy, and interviews with staff, it was determined that the facility failed to maintain an environment free of hazards related to smoking supervision for one of eleven residents reviewed. (Resident R5) Findings Include: Review of the facility policy titled Smoking Policy with a revision date of 9/2022 states, To foster the Philosophy of Caring Heart Rehabilitation and Nursing Center, in compliance with Federal and State Regulations and in accordance with HIPPA Regulations, it is the Policy of Caring Heart Rehabilitation and Nursing Center to provide a safe environment for our residents, staff and visitors by defining and enforcing smoking practices. Caring Heart Rehabilitation and Nursing Center does not permit smoking inside the facility. Smoking will be permitted in an outside designated area. Facility will be responsible for the following: 1. A covered smoking area with some protection against in-climate weather. 2. Supervision of all smokers. 3. Offer aprons, fire blankets etc. 4. A smoking assessment with periodic review by the IDT. 5.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and review of facility policy, it was determined that the facility failed to revise/update a care plan to include a new intervention related to refusals for one of 14 resident records reviewed. (Resident R12). Findings Include: Review of the facility policy titled Care Plans with a revision date of 6/2018 states, To foster the philosophy of Caring Heart Rehabilitation and Nursing Center, in compliance with Federal and State Regulations and in accordance with HIPPA Regulations, it is the Policy of Caring Heart Rehabilitation and Nursing Center to develop a comprehensive individualized care plan for each resident. Review of the clinical record for Resident R12 revealed the resident was admitted on [DATE] with several wounds including the following areas: bilateral breasts, left buttocks, right buttocks, and the sacrum. Resident R12 had orders in place starting December 1, 2024 to care for the specified wounds including the following: Under Bilateral Breasts: Cleanse with NSS…

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

Based on observation and staff interview, it was determined that the facility failed to accurately display facility daily nurse staff hours as required. Findings Include: On May 7, 2024 at 9:04 a.m. observations at the front lobby area revealed staffing was posted from April 3, 2024. Further observation of three of five floors (Second, Third, and Fifth) revealed there was no other staffing posted throughout the building. Interview with the Director of Nursing, Employee E2 on May 7, 2024 at 1:02 p.m. revealed the staffing coordinator, Employee E11 confirmed the staffing was not up to date. The staffing coordinator stated that the staffing posted in the lobby was also inaccurate as it was actually the staffing from April 10, 2024. The Director of Nursing, confirmed on May 7, 2024 at 1:05 p.m. there was a failure to keep the staffing posting current to date. 28 Pa. Code 211.12 (d)(1)(3)(4) Nursing Services

Based on observations, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure that menus were followed on two of eight nursing units observed (4 Cliveden unit, 5 Cliveden.) Findings include: Interview on October 24, 2023, at 11:00 a.m. with eleven alert and oriented residents (Residents R4, R145, R102, R86, R84, R20, R50, R168, R206, R132 and R233), revealed that residents stated that menus were never posted or followed, that they never knew what they were going to get, that the food quality was poor, that they do not like the eggs, they do not like the brown gravy and that meats were dry, overcooked and difficult to chew. The residents stated that they have expressed their concerns during food committee meetings, but that there has been no response from the facility and that food service has been getting worse. Review of food committee meeting minutes from June 2023, revealed that residents requested to have more breakfast meats, more egg whites and to have croissants. Review of food committee meeting minutes…

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 of the food and nutrition department, reviews of the cleaning checklist for the main kitchen and interviews with staff, it was determined that foods and beverages were not being stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: A tour of the main kitchen was completed with the director of dietary services, Employee E8, on October 23, 2023 at 10:30 a.m. Additional observations were made with the director of dietery services on October 24, 2023m at 1:30 p.m. Shelving inside the walk-in refrigerator units in the main kitchen contained a heavy accumulation of food spillage, dirt, rust and food debris. This unit was holding prepared food items in roasting and baking pans, fresh vegatables and fruits in carboard boxes and cartons of milk and eggs and plastic wraped cheese and meats, and boxes of whole eggs. The working mechanisms of the three compartment sink were not functioning properly. The plumbing underneath the sinks along with the drain connection stopper were not holding water for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of clinical records and facility policy and procedures and staff interviews, it was determined that the facility failed to develop a baseline care plan regarding stoma and colostomy care for one of 38 residents reviewed. (Resident R41). Findings include: Review of facilities policy, Comprehensive Care Plans, dated August 22, 2023, revealed that the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, which includes measurable objectives and time frames to meet a residents medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment. A review of Resident R414's clinical record revealed that the resident was admitted to the facility on [DATE], with a diagnosis of gastroesophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Observation of Resident R414 in room [ROOM NUMBER] on October…

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 and interviews with residents and staff, it was determined that the facility failed to ensure that meals were served in a timely manner on one of eight nursing units observed (4 Cliveden unit). Findings include: Review of facility documentation, Dining Services Truck Delivery Schedule revealed that breakfast trays are scheduled to arrive on the 4 Cliveden unit at 8:30 a.m. and 8:35 a.m. Continued review revealed that lunch trays are scheduled to arrive on the 4 Cliveden unit at 12:25 p.m. and 12:30 p.m. Further review revealed that meal trays are expected to be delivered to units within ten minutes of their scheduled time. Observation on October 23, 2023, of the 4 Cliveden unit revealed that the first truck of meal trays did not arrive to the unit until 1:02 p.m. Continued observation, on October 23, 2023, at 1:14 p.m. revealed that Resident R198 was served her lunch tray, but that there was no beverage provided with her meal. Resident R198 stated that her water cup was also empty and that she did not have anything to drink…

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 and interviews with residents and staff, it was determined that the facility failed to ensure that foods and beverages served were palatable, attractive and satisfying for the residents. Findings include: Interview on October 24, 2023, at 11:00 a.m. with eleven alert and oriented residents (Residents R4, R145, R102, R86, R84, R20, R50, R168, R206, R132 and R233), residents stated that menus were never posted or followed, that they never knew what they were going to get, that the food quality was poor, that they do not like the eggs, they do not like the brown gravy and that meats were dry, overcooked and difficult to chew. The residents stated that they have expressed their concerns during food committee meetings, but that there has been no response from the facility and that food service has been getting worse. Review of food committee meeting minutes from October 2023, revealed that residents reported that foods tasted bland and needed seasoning. Observations of the luncheon meal on October 23, 2023, at 1:05 p.m. on the 4…

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 ensure that snacks were available on the nursing unit for a resident who requested a snack, for one of 44 residents reviewed (Resident R126). Findings include: Review of Resident R126's Annual MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated March 2, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose), Parkinson's Disease (a progressive disorder of the nervous system that affects movement) and malnutrition (lack of sufficient nutrients in the body). Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating that she was cognitively intact. Further review revealed that it was very important to the resident to…

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

Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain complete and accurate clinical records related to enhanced barrier precautions for one of 44 residents reviewed (Resident R12). Findings include: Review of facility policy, Enhanced Barrier Precautions dated October 10, 2023, revealed that enhanced barrier precautions refers to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO (multi drug resistant organism) as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). Observation, on October 23, 2023, at 10:36 a.m. revealed that Resident R12's room door had signage posted indicating that the resident required enhanced barrier precautions. Review of Resident R12's care plan, dated initiated February 25, 2015, revealed that the resident had skin impairments and an indwelling urinary catheter. Further review of Resident R12's care plan, as…

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

Based on observation, review of the facility policy and staff and resident interview, it was determined that the facility failed to ensure that call bells were available and operable for resident use for one of 38 residents observed residents. (Residents R21) Findings include: Review of facility policy, Preventive Maintenance Program, dated May 1, 2023, revealed that the Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the building, grounds and equipment are maintained in a safe and operable manner. Interview with Resident R21 conducted on October 23, 2023, at 12:50 p.m. revealed that she was having difficulty with her call bell. She stated that she has to push it multiple times and it does not always work. Observation of her call bell jack on her wall revealed that the light did not light up. Further observation of the light on the ceiling outside her door revealed that it was not light after pressing the button multiple times. Interview with Registered nurse, Employee E7, on October 23, 2023, at 12:57 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.

Based on observations of the food and nutrition department and the ground floor of the building, reviews of the pest control operator's reports and policies and procedures and interviews with staff, it was determined that the facility was not maintaining an effective pest control. Findingsinclude: A review of the policy titled Pest control program dated January 5, 2023 revealed that it was the responsibility of the facility to maintain an effective pest control program to eradicate pests and rodents. The policy said that the facility would use a variety of methods in controlling pests and rodents by working closely with the consulting licensed pest control operator. Observations of the layout and design of the facility, it was noted that the food and revealed that the food and nutrition department, staff breakroom, laundry department and lobby were located on the ground floor of the facility. Observations of the double doors leading directly outside to the garbage and refuse area, revealed that upon closing the doors, there was an obvious two inch gap located at the threshold. 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.