Cliveden Nursing And Rehabilitation Center

Based on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system that includes antibiotic use protocols and a system to effectively monitor antibiotic usage for 10 of 10 months of antibiotic stewardship program data reviewed. (January 2025, February 2025, March 2025, April 2025, and May 2025). Findings Include: A review of CDC (Centers for Disease Control and Prevention) guidelines, The core element of Antibiotic Stewardship for Nursing Homes, revealed that Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. 1. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.2 The Centers for Disease Control and Prevention (CDC) recommends that all acute care hospitals implement an antibiotic stewardship program (ASP) and outlined the seven core…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interviews, it was determined that the facility failed to offer and/or provide the influenza and pneumococcal immunization for three of five residents reviewed (Resident R117, R295, R32, R62, and R95). The findings include: Review of the clinical record for Resident R117 revealed the resident was admitted to the facility on [DATE]. Resident was [AGE] years old. Review of R117's immunization records revealed no evidence that the resident received the pneumococcal vaccine, or the facility offered the pneumococcal vaccine. Facility did not offer or administer influenza vaccine. Review of the clinical record for Resident R295 revealed that the resident was [AGE] years old. Review of R295's immunization records revealed no evidence that the resident received the pneumococcal vaccine, or the facility offered the pneumococcal vaccine. Review of the clinical record for Resident R32 revealed that the resident was [AGE] years old. Review of R32's immunization records 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 staff interviews, review of facility policy and the review of the clinical record, it was determined that the facility failed to ensure that a resident received proper notification for a room change, and failed to ensure that the resident had the opportunity to refuse a room change for 1 out of 29 residents reviewed (Resident R11). Findings include: Review of the facility policy, Room Change/Roommate Assignment, dated April 1, 2022 indicated that changes in room or roommate assignment shall be made when the facility deems it necessary or when the resident requests the change. Changes in room or roommate assignment shall be made when the facility deems it necessary or when the resident requests the change. The policy also stated that prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents or their representatives (sponsors)) will be given advance notice of such change. Continued review of the policy indicated that he notice of a change in room or roommate assignment may be oral or in writing, or both, and will include 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, resident and staff interviews, it was determined that facility failed maintain a safe, clean comfortable and home like environment for residents of one of three nursing units. (Third floor) Findings Include: Observation of Third floor nursing unit on June 10, 2025, at 9:45 AM revealed there was a strong odor of urine throughout the South unit hallway. Observation of Third floor nursing unit on June 10, 2025, at 9:52 AM revealed there was a strong odor of urine throughout the [NAME] unit hallway. Interview with the Licensed Practical Nurse, Employee E23, on June 9, 2025, at 9:52 AM confirmed that there was strong odor of urine on both hallways. Employee E3 stated it could be from staff changing the residents. A follow up tour of the south hallway on June 10, 2025, at 10:00 AM revealed that there were no residents receiving incontinence care. Observation of Third floor nursing unit on June12, 2025, at 10:41 AM revealed there was strong odor of on the [NAME] hallway. Observation of the Third-floor dining room on June11, 2025, at 10:35 AM revealed that there was…

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 emergency transfers to the hospital for 3 of 29 residents reviewed (Residents R83, R137 and R118). Findings Include: Clinical record review for Resident R83 revealed progress notes, dated October 15, 2024, at 11:18 a.m. and 1:06 p.m. which indicated that the resident had increased abdominal girth and no bowel movement in 72 hours (three days) and was ordered by the physician to be transferred to a local hospital for evaluation. Clinical record review for Resident R137 revealed a progress note, dated May 1, 2025, ay 11:12 p.m. which indicated that the resident had abnormal labs and was ordered by the physician to be transferred to a local hospital for evaluation. Review of Resident R118's clinical record revealed a nursing progress note dated January 19, 2025, that indicated the resident had an unwitnessed fall and sustained a hematoma (collection of blood that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to follow up dental consults related to recommendations for dentures, for 1 out of 29 residents reviewed (Resident R97). Findings include: Review of the facility policy, Dental Services, with a date of April 1, 2022 indicated that the facility has a contract with a dentist who comes to the facility and provides dental services on a monthly basis. Continued review of the policy indicated that a designated staff member is responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary. Review of the June 2025 physician orders for Resident R97 included the diagnosis of dysphagia (difficulty swallowing). During an interview with Resident R97 on June 11, 2025 at 1:00 p.m. the resident reported that he has been trying to get help from the facility with getting new upper dentures, and that he has a hard time chewing his food properly due to no longer having his upper…

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 residents and staff, it was determined that the facility failed to assist a resident to obtain an audiologist consult for hearing aides, for one of 29 residents reviewed (Resident R117). Findings include: Interview on June 10, 2025, at 11:27 a.m. Resident R117 stated that he had difficulty hearing and needed hearing aids. Resident R117 stated that he was evaluated by a doctor for hearing loss, but that he has not received his hearing aides yet. Clinical record review for Resident R117 revealed an Ear Nose and Throat (ENT) Consultation Report, dated June 18, 2024, which indicated that the resident had suspected hearing loss, and recommended an audiology (branch of medicine focused on hearing) and hearing aide evaluation. Further review of Resident R117's clinical record revealed that there was no documentation available for review at the time of the survey to indicate if the resident received the audiology and hearing aid evaluations that were recommended by the ENT specialist. Interview on June 12, 2025, at 9:26 a.m. Employee E3,…

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 residents, review of facility policy and review of clinical records, it was determined that the facility failed to ensure that a device to prevent contractures was applied as order by the physician for one out of 29 residents reviewed (Resident R97) Findings include: Review of the June 2025 physician orders for Resident R97 included the following diagnosis: heart failure (occurs when the heart muscles don't pump blood as well as they should); diabetes (a disease characterized by high blood sugar levels); and dysphagia (difficulty swallowing). Continued review of June 2025 physician orders included a physician order with a start date of February 16, 2023 for RUE (right upper extremity) elbow extension splint and resting hand splint on in a.m. and off in p.m. with skin checks prior to donning (putting on) and post doffing (removing) every morning and at bedtime. Review of the resident's person-centered plan of care included a plan of care dated February 19, 2023 stating that the resident required restorative programs related to contracture management so that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observations, and staff and resident interviews, it was determined that the facility failed to provide necessary respiratory care consistent with professional standards of practice for one of three residents reviewed for tracheostomy (Resident R127). Findings Include: Review of facility policy Tracheostomy Care revised October 4, 2024, revealed it is the policy of the facility to establish standards for the care and maintenance of tracheostomy tubes. Per the policy, trach care sohuld be performed daily and as needed for dressing soilage. This includes removal of drain/dressing sponge and cleasing around stoma site and trach plate. Review of Resident R127's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 27, 2025, revealed the resident was admitted to the facility on [DATE], was determined cognitively intact, and had diagnoses of respiratory failure (when the respiratory system fails 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 review of facility documentation, review of personnel files and interviews with staff, it was determined that the facility failed to assure that nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs for three of five personnel files of newly hired staff reviewed (Employees E8, E9 and E10). Findings include: Review of the facility's job description for nurse aides revealed that nurse aide staff are responsible for providing direct personal care to residents, including performing restorative nursing and rehabilitative procedures, serving meals trays, assisting residents with feeding, assisting residents with transferring, lifting and ambulating, and providing incontinence and skin care. Review of the facility's job description for licensed practical nurses (LPNs) revealed that LPNs are responsible for providing direct nursing care to residents, including administration of medications, treatments and direct care according to physician orders. Review of facility documentation of newly hired 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.

Based on a review of facility documentation and interviews with staff, it was determined that the facility failed to complete performance reviews for three of three nurse aides personnel files reviewed related to performance reviews as required (Employees E11, E12 and E13). Findings include: Review of facility documentation pertaining to current employees, revealed that Employee E11 was hired by the facility as a nurse aide on July 14, 1996; Employee E12 was hired as a nurse aide on September 15, 1988; and Employee E13 was hired as a nurse aide on November 26, 2007. Interview on June 11, 2025, at 10:03 a.m. Employee E5, HR Director, revealed that the facility had not completed any performance reviews for any staff, including Employees E11, E12 and E13. 28 Pa. Code 201.19(2) Personnel policies and procedures

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and review of manufacturers' guidelines, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards of practice for two of four medication carts observed. (Third floor east and south medication carts). Findings Include: Review of manufacturer's guidelines for Humalog Insulin (insulin lispro) (medication used to treat high blood sugar levels) revealed that Humalog must be discarded 28 days after opening. Review of manufacturer's guidelines for Lantus Insulin(insulin glargine) revealed that the medication must be discarded 28 days after opening. Review of manufacturer's guidelines for Novolin Insulin revealed that the medication must be discarded 28 days after opening. Review of manufacturer's guidelines for Novolog Insulin (insulin aspart) revealed that the medication must be discarded 28 days after opening. Unopened vials should be refrigerated unit use.…

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 records and staff interview. it was determined that the facility failed to ensure that a resident with out dentures was assess for speech rehabilitation services for 1 out of 29 residents reviewed (Resident R97). Findings include: Review of the June 2025 physician orders for Resident R97 included the diagnosis of dysphagia (difficulty swallowing). During an interview with Resident R97 on June 11, 2025 at 1:00 p.m. the resident reported that he has been trying to get help from the facility with getting new upper dentures, and that he has a hard time chewing his food properly due to no longer having his upper dentures. The resident reported that his teeth were thrown away on his food tray by staff, and that he was notified by the facility that Medicaid will not pay for replacement dentures. Residnet R97 was observed with no upper dentures/teeth in his mouth during the above referenced interview. Review of an onsite dental consultation visit dated April 15, 2025 indicated that the resident told…

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, interview with residents and staff, and review of facility policy, it was determined that the facility did not ensure to provide safe, homelike environment for four out of five rooms observed (Room's 301, 302, 303, 304) Findings include: Review of facility's policy 'Resident Rights - Safe/Clean/Comfortable/Homelike Environment,' revised April 1, 2022, indicates that the facility must provide a safe, clean, comfortable, and homelike environment .housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observations on January 31, 2025, at 1:00 pm, on third floor unit, in room#301, revealed a missing ceiling tile in resident's restroom, six leaking stains ceiling tiles, leaking stain down the wall in restroom. Observation of room# 302 revealed leaking stains on ceiling tiles above resident's bed. Observations of room# 304 revealed missing ceiling tile and three leaking stains on ceiling tiles. Observations of room# 303 revealed leaking stains on two ceiling tiles. Interview with Resident R5, in room# 304, bed A,…

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

Based on observation's, interview with resident and staff, it was determined that the facility failed to ensure that a call device was accessible to one out of nine residents observed (Resident R6) Findings include: Review of facility policy 'Call Bells,' revised April 1, 2022, indicates that all residents are to have access to call bells at all times, even if it is generally believed that the resident is unable to use it. Staff are expected to be as vigilant as possible in keeping the call bell within reach of the resident, and the call system must be accessible to residents: while in their bed. Review of Resident R6's clinical record on January 31st, 2025, revealed medical diagnosis of hemiplegia and hemiparesis (paralysis and weakness) following cerebral infarction affecting left non-dominant side, muscle wasting and atrophy, generalized muscle weakness, morbid obesity. Observations of R6 during lunch meal service, on January 31, 2025 at 12:30 pm, revealed Resident R6 in bed with lunch tray on bedside table over Resident R6's bed. Further observation of Resident R6 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 observation and interviews with residents and facility staff, it was determined that the facility failed to provide care and services to enhance residents' dignity related to serving meals on disposable paperware, serving residents meals timely on one of three dining rooms (Third floor dining room) and no catheter dignity bag for one of 28 Residents reviewed (Resident R244). Findings include: Observations during the initial tour of the facility on August 27, 2024, at 10:50 a.m. in Resident R244's room revealed that resident had an indwelling foley catheter in place and that the urine collection bag attached to the catheter was hanging from the side of the bed not covered with a dignity bag exposing a clear plastic bag with a amber colored fluid inside of it. The urine collection bag was clearly visible through the doorway hallway. Interview with the Licensed nurse, Employee E9, on August 27, 2024, at 11:15 a.m. confirmed that Resident R100's catheter bag, which was hanging on the side of her bed, was visible from the doorway and was not covered. During further 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 observations and interviews with residents and staff, it was determined that the facility failed to provide a drawer or cabinet in the resident's room that can be locked for storage of the resident valuable items for two of 35 residents reviewed. Findings include: Review of facility policy, Inventory of Resident Personal Belongings/ Property, revised July 1, 2023, revealed that, Money, jewelry, or collectibles should be kept in a lock drawer. If a resident doesn't have a key, one will be provided. Observations during the initial tour of the second-floor nursing unit on August 27, 2024, at 11:30 a.m. in room [ROOM NUMBER], bed A revealed a wardrobe with a silver hasp, but no lock and the top drawer on the chest next to her bed had a lock. Interview with Resident R77, who lives in room [ROOM NUMBER], Bed A, revealed that she was missing almost all of her tops, and that they told her that they would lock them in her wardrobe so that they would be safe, but she did not have a lock for the wardrobe. She…

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 personnel records and interview with staff, it was determined that the facility did not provide requested evidence of competency trainings for licensed nursing staff for four of four employees records review. (Employees E9, E18, E20, and E21) Findings include: On August 29, 2024, at 2:15 p.m., the surveyor requested skills competency evaluations for Licensed Nurses, Employees E9, E18, E20, and E21. The requested skills were to related to medication administration, oxygen administration, care of gastrostomies and administration of nutrition, tracheostomy care, wound care, and abuse prevention and reporting. In an interview on August 30, 2024, at 10:30 a.m. with the Nursing Home Administrator, Employee E1, stated that the facility was unable to supply the surveyor with all of the requested skills competencies for the nurses, stating that they didn't have them. 28 Pa. Code: 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review and interview with staff, it was determined that the facility did not provide requested evidence of yearly performance reviews for nurse aides. Findings include: On August 29, 2024, at 12:39 p.m., an email was sent to the Nursing Home Administrator, Employee E1 requesting evidence of yearly performance reviews for nurse aides. During an interview on August 30, 2024, at 10:15 a.m. the Director of Nursing, Employee E2 stated that there were no yearly reviews for the nurse aides. 28 Pa. Code: 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: An initial tour of the Food Service Department was conducted on August 27, 2024, at 9:30 a.m. with Employee E4, Food Service Director (FSD), which revealed the following: Observation in the receiving area revealed trash including paper and plastic on the ground near the door and dumpster. Observation in the walk-in refrigerator revealed a dark substance on the walls and an accumulation of dirt and dust on the floor, especially in the corners. Observation in the hot food production area revealed a prep table with the undershelf setting directly on the ground, the shelf was pitted with rust colored stains and there was no way to clean under it without moving it. Further observations revealed the outsides of the convection oven and reach-in refrigerator were covered with a layer of grease and grime, and the door gaskets were torn on the right door…

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 ensure that a resident was allowed to participate in decisions regarding medical appointment requests for one of twenty-eight residents reviewed. (Resident 135). Findings Include: Interview with Resident R135 on August 27, 2024 at 9:52 a.m. revealed the resident had concerns with seeing outside physicians which she had mentioned multiple times and no one ever followed through with giving her an answer or scheduling any appointments with her. Review of Resident R135's clinical record revealed on August 1, 2024 there was an Interdisciplinary Progress Note that stated, Care Conference scheduled on 8/1/24. IDT (Interdisciplinary Team) visited with resident by bedside. Resident had concerns for nursing and the in-house physician. Resident wishes to get vitamin supplements D-3, to get print out of all their medications getting. Requesting to see the cardiologist specialist at (hospital). Wanting to get a MRI x-ray to check why not using legs. Requested to be updated when they 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.

Based on the tour of facility, observations and interviews with staff, it was determined the facility failed to ensure State Department of Health information was posted visible in a prominent place to residents in two out of three of the units. (Second Floor and Third Floor) Findings include: On August 28, 2024 at approximately 11:11 a.m. a tour of the facility with Social Worker, Employee E14 and it was determined that only one of three units had the State Department of Health contact information posted and visible for residents and/or family. The first floor has a paper printed State Department of Health signs with small print that were posted in a glass case before you entered unit one. The printed paper we posted high in the glass case which would make it non-visible for residents who were wheelchair bound. A tour of the second-floor nursing unit revealed no printed State Department of Health signs located on the unit. A tour of the third-floor nursing unit revealed no printed State Department of Health signs located on the unit. Social Worker Employee E14 confirmed the facility…

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

Based on observation, staff interview, review of clinical record, it was determined that the facility failed to maintain privacy related to personal privacy during tracheostomy care and sensitive patient health information during medication administration for three of 28 residents reviewed (Resident R9, Resident R121, and Resident R97). Findings include: Medication administration observation with Licensed nurse, Employee E18 conducted on August 28, 2024, at 9:05 am revealed that after preparing the morning medications for Resident R9 Employee E18 went inside Resident R9's room to give her medications. Further observation revealed that Employee E18 left her laptop open with the laptop facing the hallway with Resident R9's medical information visible. Further medication administration observation with Employee E18, revealed that, during medication administration for Resident R121, after preparing the morning medications for Resident R121, Employee E18 went inside Resident R121s room to give him his medications. Further observation revealed that Employee E18 left her laptop open with…

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

Based on observations, review of facility policy, review of facility records, and interviews with residents and staff, it was determined that the facility failed to ensure that grievance forms were accessible for residents who wish to file a grivance anonymously and there was no grievance box availble on two of three nursing floors (First and Third floor). Findings Include: Review of facility policy titled, Grievance Program dated April 1, 2022 states, Purpose: To promote an environment and culture open to feedback positive and or negative from residents, family members, employees, physicians, and any other visitors. Both positive and negative comments from these individuals helps to provide information which will be incorporated into policies, procedures, and practices within the organization that focus on creating a culture of excellence through identification and resolution within continuous quality improvement. Right to file Grievances: residents and visitors have the right to present concerns/grievances on behalf of himself or herself or others to the staff or administrator of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview with staff, it was determined that the facility did not ensure that resident assessments accurately reflected resident status related to discharge for one of three closed records reviewed (Resident R141). Findings include: Review of clinical documentation revealed that Resident R141 was admitted to the facility on [DATE], and discharged from the facility on June 11, 2024. A nursing note written on June 11, at 8:11 p.m. stated, Resident discharged . Left facility at about 5pm via medical transport with family. All scripts and personal belongings were taken by family prior to discharge. Home care services referral in place. The resident's discharge instructions, signed by licensed nurse, Employee E15, on June 11, 2024 included referral for homecare physical therapy and occupational therapy services. Review of the resident's discharge MDS (Minimum Data Set, a periodic evaluation of resident needs), section A2105, Discharge Status, signed on June 14, 2024, by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, review of clinical records, and staff interviews, it was determined at the facility failed to develop a baseline care plan that includes the instructions needed to provide effective and person-centered care within 48 hours of admission for respiratory care, pressure ulcer, catheter, and pain for three of twenty-eight residents reviewed (Residennt R130, Resident R138 and Resident R444). Findings include: Review facility policy for baseline care plan, comprehensive care plan, and ongoing care plan updates dated April 1/20/22. Reveal that under section Policy Statement: Bedrock Care will follow a uniform process for initiating the baseline care plan upon admission, the Comprehensive Care Plan upon CAA completion and ensuring care plans are updated to reflect the resident's status. Under subsection baseline care plan. The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered 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 review of facility policy, review of clinical records, and interviews with staff it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for three of twenty-eight residents reviewed. (Residents R31, R55, R97) Findings Include: Review of facility policy titled Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates dated April 1, 2022 states, Policy Statement- Facility will follow a uniform process for initiating the baseline care plan upon admission, The Comprehensive care plan upon CAA completion, and ensure care plans are updated to reflect the resident's status. Further review of the policy states, Ongoing updates to care plans- Nursing staff will update the care plan related to physician's orders and/or changes in care needs. The nursing staff will initiate and/or update acute care plans for the resident as they are warranted. Resident R31 was observed on August 27, 2024 at 11:01 a.m. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, review of facility policy, and interviews with residents and staff, it was determined the facility failed obtain a physican order for tracheostomy care and suctioning for one resident and failed to notify the physician after one resident missed medication doses for two out of 28 residents reviewed. (Resident R 97 and Resident R138) Findings include: Tracheostomy care observation for Resident R97 with Employee E17 conducted on August 30, 2024, at 8:50 am revealed that Employee E17 performed tracheostomy care dressing of tracheostomy site with normal saline, replaced the disposable inner cannula and suctioned Resident R97. Review of Resident R97's clinical record revealed that there was no physician's order to suction Resident R97. Interview with Director of Nursing, Employee E2 conducted on August 30, 2024, at 9:38 a.m. confirmed that there were no orders for suctioning. Employee E2 further stated that she will have an order for suctioning put in. Review of Resident R138's…

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

Based on review of facility policy, review of clinical records, observations, and interviews with staff, it was determined that the facility failed to ensure that physician orders were followed regarding oxygen administration for two of two residents observed on oxygen. (Resident R4 and R31) Findings Include: Review of facility policy titled, Oxygen Administration with a policy date of December 4, 2023 state, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. Steps in the Procedure: Wash and dry your hands thoroughly. Remove all potentially flammable items from the immediate area where the oxygen is to be administered. Check the tubing connected to the oxygen cylinder to assure that it is free or kinks. Turn on the oxygen. Unless otherwise ordered, start…

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 facility documentation and interviews with staff, it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider for three of eight dialysis residents reviewed (Residents R44, R133 and R28). Findings include: A review of the Dialysis Policy dated April 1, 2022, revealed that the facility will utilize the Dialysis Communication form each time a resident attends dialysis as a tool to relay pertinent information regarding the resident's condition and coordinate care and services with the dialysis provider. Review of Resident R33's clinical record revealed that the resident was admitted on [DATE], with diagnoses including but not limited to end stage renal disease (condition where the kidney reaches advanced state of loss of function). Further review of Resident 33's clinical record revealed that the resident has dialysis treatments three times per week on Monday, Wednesday and Friday at 5:15 a.m. at a dialysis center.…

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, it was determined that the facility failed to provide pharmaceutical services to assure the acquiring and administering of medications to meet the residents need of one resident for one of twenty-eight residents reviewed. (Resident R138) Findings include: Review of Resident R138's clinical record revealed that Resident R138 was admitted to the facility on [DATE] with diagnoses of Extradural and Subdural Abscess, Dorsalgia (Dorsalgia is a collective name given to a group of conditions that produce moderate to intense pain in the muscles, nerves, bones, joints, or other structures associated with the spinal column of the body.), Osteomyelitis of the vertebra (lumbar region) and infective myositis (Infectious myositis is a rare infection of the skeletal muscles caused by a variety of pathogens, including bacteria, fungi, viruses, and parasites.)of unspecified left leg, Opioid Abuse. Further review of Resident 138's clinical record revealed the following 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for three of 36 residents clinical records reviewed (Resident R18 and R35). Findings Include: Review of the Pharmacy Services: Drug Regimen Review Policy dated October 24, 2022, revealed, the pharmacist will report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports will be acted upon. Review of Resident R18's clinical record revealed that resident was admitted on [DATE], with diagnoses including anxiety. A review of Resident R18's pharmacy progress notes revealed the following note: August 6, 2024 - Medication Regimen Reviewed. Recommendations made. SeeMedication Regimen Review Report. Further review of Resident R18's clinical record revealed no further pharmacy notes or recommendations related to the August 6, 2024, recommendation. Interview with the Director of…

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

Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employees E4). Findings include: An interview on August 27, 2024, at 9:30 a.m. with Employee E4, Food Service Director (FSD), revealed that her responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Further interview with the FSD confirmed that she was not currently a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; or had an associate's or higher degree in food service management or hospitality from an accredited institution; and that she had not received frequently scheduled consultations from a qualified dietitian. A review of Employee E4's credentials revealed that Employee E4 did not meet the statutory qualifications of a director of food and nutrition services. During an interview on August 30, 2024, at 10:30 a.m. with the Administrator, 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 documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature for three of eight residents interviewed (Residents R52, R236 and R6). Findings include: A review of Test Tray form revealed that the standard temperature range for Entrée, Starch and Vegetable was 135° F, and milk and cold beverage were 45° F. Interview on the second floor with Resident R52 on August 27, 2024, at 10:40 AM revealed that the food is not great, and not aways warm enough, and too many eggs, and has not been getting her milk. Interview on the second floor with Resident R136 on August 27, 2024, at 10:45 AM, at 10:55 AM revealed that for the past four to five days he was not getting coffee, no milk and no ice cream listed on his ticket, and for breakfast he is only getting one yogurt, and the food is not always hot when he is served. Interview on the second floor with Resident R77 on August 27, 2024, at 10:50 AM revealed that she does not like the food, it is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility documents and resident clinical records and interviews with staff and residents, it was determined that the facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for three of nine residents reviewed (Resident R56). Findings include: Review of Attachment 19, Binding Arbitration Agreement, found on page 72 of the facilities admission Agreement revealed, The Arbitration Agreement was explained to the Resident, his/her Resident Representative, or Guardian with legal authority to enter into the Arbitration Agreement in the case of a Resident without capacity signing below, in a form and manner that he or she understands, including in a language the Resident and his/her Resident Representative signing below understand. Interview on August 29, 2024, at 1:15 p.m., with the Administrator, who was on the phone with the admission Director, who was home on a medical leave, revealed that the admission Director stated that all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of facility observations and interviews with resident and staff, it was determined that the facility failed to ensure a safe, functional, sanitary environment on three of three nursing units observed. (1st , 2nd, 3rd floor nursing units) Findings: On May 8, 2024, at 9:41 a.m. observation tour was conducted with the Administrator, Employee E1 and confirmed the followings: First floor nursing unit, room [ROOM NUMBER] bathroom had a detached heating baseboard, 4 basins stored on the top of the sink. room [ROOM NUMBER] baseboard behind the bed A was missing. room [ROOM NUMBER] & 113 had a detached heating baseboard. room [ROOM NUMBER] had a strong urine odor. Second floor room [ROOM NUMBER] had a hole in the wall above the B bed. Third floor room [ROOM NUMBER] bathroom was missing a cover to the toilet paper roll. Bed A had a dirty floor mat with large stain spots and each of the angle of the mat was ripped out. Resident R3 reported she just moved into the room and the floor mat doesn't below…

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 staff and residents, review of the facility tray audit form, and the completion of a lunch test tray, it was determined that the facility failed to provide food and drinks that were served at appetizing temperatures on one of three nursing units (2nd floor nursing unit). Findings include: Review of the resident tray audit form utilized by the facility to assess the temperature and quality of the food revealed that hot food items and hot beverages should be a minimum temperature of 135 degrees Fahrenheit at point of service. Further review of the tray audit form revealed that cold desserts and cold beverages, should be served at a maximum temperature that is less than or equal to 50 degrees at point of service. Interview with residents on December 26, 2023 regarding their meal temperatures, the following was reported: Interview with Resident R8 at 10:40 a.m., the resident reported, Breakfast is always cold. Interview with Resident R9 at 10:42 a.m. where Resident R9 stated, in reference to food temperatures, I very rarely get anything hot around here. Resident…

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

Based on observations, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure dignity for residents related to the use of plastic utensils during the lunch time meal (Resident R1, R2, R3, R4, R5, R6), and for one resident who required assistance with feeding from nursing staff (Resident R6), for 6 out of 6 residents reviewed. Findings include: During a dining observation on December 26, 2023, during the lunch time meal on the 2nd floor nursing unit residents were observed eating their lunch time meals with white plastic utensils. During an observation on December 26, 2023, at 12:30 p.m. in the 2nd floor dining room, Resident R2, Resident R3 and Resident R4 were observed in the dining room being fed by nursing staff with white plastic utensils. Observation on December 26, 2023 at 1:00 p.m. on the 2nd floor nursing unit, Resident R1 was observed in her room at 1:00 p.m. eating her lunch time meal with white plastic utensils. Observation on December 26, 2023, at 1:03 p.m. on the 2nd floor nursing unit, Resident R5 was observed being…

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, residents and staff interviews and review of clinical records, it was determined that the facility failed to ensure a clean, safe, comfortable homelike environment for 1 out of 3 nursing units (3rd floor nursing unit). Findings include: Review of the November 2023 physician orders for Resident R16 included the diagnoses of diabetes (a group of diseases that affect how the body uses blood sugar), hypertension (high blood pressure) delusions (a type of mental health condition in which a person can't tell what's real from what's imagined) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident R16's Quarterly Minimum Data Set assessment dated [DATE], indicated that Resident R16 was cognitively impaired. During a tour on the 3rd floor nursing unit on November 14, 2023 at 10:00 a.m. an odor of urine mixed with other unpleasant odors that cannot be described could be detected on the floor upon approaching Resident R16's room despite 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, reviews of policies and procedures and interviews with residents and staff, it was determined that the facility failed to developed a plan of care for refusal of medication for one of seven residents with mood and behavioral needs. Resident R35) Findings include: A review of the facility policy titled Behavior Management dated April 1, 2022 revealed that the staff and physician were responsible for identifying residents with dementia, problematic behavior and mental illness. The policy also said that the staff and physician were responsible for treatment and management of each resident's mental disorder. The policy indicated that a psychiatric consult was to be called for each resident to manage behavioral issues. A review of the facility policy titled Refusal of Care dated January 3, 2022 indicated that the in light of care refusal by a resident, the interdisciplinary team would make every effort to obtain compliance with the plan of care. The interdisciplinary team members were to confer…

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 residents, review of facility policy and staff and review of clinical records, it was determined that the facility failed to ensure that one resident participated in the restorative care nursing program to maintain, improve, or prevent avoidable decline in range of motion and mobility for one out of 34 residents reviewed (Resident R44). Findings include: Review of the facility policy, Specialized Rehabilitation and Restorative Services, dated April 1, 2022 indicated that the facility will ensure that specialized rehabilitation services are provided under the written order of a physician by qualified personnel. The policy also stated that the facility will provide restorative services when necessary, as indicated by the assessment of the interdisciplinary team, such as, but not limited to walking, transfer training, bowel and bladder training, bed mobility, Range of Motion, eating and/or swallowing, amputation/ prostheses care and communication, in addition to splint and brace. Review of the November 2023's physician orders for Resident R44 indicated 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 observation, clinical record review and staff interview, it was determined that the facility failed to ensure that physician orders were followed related to the size of an indewelling urinary cathter for one of one residents reviewed with a urinary catheter. Findings include: Review of Resident R91's clinical records that the resident was admitted to the facility on [DATE] with the diagnosis of Neuromuscular Dysfunction of Bladder (the nerves and muscles do not work together very well. As a result, the bladder may not fill or empty correctly. Bladder muscles may be overactive and squeeze more often than normal and before the bladder is full of urine). Review of physician order dated June 23, 2019, for Resident R91, indicated an order for Suprapubic Catheter Size 16 FR, 10cc balloon. Observation conducated on November 17, 2023, at 10:57 a.m. of Resident R91's suprapubic catheter in the presence of Licensed nurse, Employee E9, the resident had Suprapubic Catheter Size 16 FR, 30cc balloon. At the time of…

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

A review of the skills training and competency records for the nursing staff, staff interview, review of facility policies and facility assessment, it was determined that appropriate competencies and skills sets were not provided for the nursing staff related to dementia management and behavioral health care. Findings include: A review of the policy titled Training Program dated November, 2017, revealed that it was the responsibility of administrative staff to provide staff with the necessary training consistent with their expected roles to provide quality of care and services to the resident population. The policy also indicated that each nursing staff member was to receive dementia management training and competencies for challenging behaviors, conflict resolution and anger management. A review of facility documentation provided by the administrative staff on November 14, 2023 revealed that there were 154 residents living in the facility. Of the 154 residents 61 of the residents were identified with dementia care needs. A review of the facility wide assessment indicated 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 clinical record review and interviews with staff, it was determined that the facility did not ensure that the consultant pharmacist's recommendations were implemented in a timely manner for two of five records reviewed (Residents R30 and R46). Findings include: Review of clinical records revealed that Resident R30 was admitted to the facility on [DATE]. Review of clinical documentation revealed that the consultant pharmacist had made recommendations for Resident R30 on June 6, 2023 as follows: currently (Resident R30) receiving Atorvastatin (Lipitor) for dyslipidemia (unhealthy levels of one or more kinds of lipid (fat) in blood). Unable to locate recent serum lipid profile (a common blood test that healthcare providers use to monitor and screen for an individual's risk of cardiovascular disease) in chart. Recommended three months after start then annually thereafter. Please consider ordering. Further review of the recommendation revealed that the physician had noted and agreed with the pharmacist's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, observations and resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 30 residents reviewed (R22, R91). Findings include: Review of Resident R22 clinical record revealed that the resident was admitted to the facility on [DATE], and readmitted on [DATE]. R22 had diagnoses including Encounter for surgical aftercare following surgery on the Genitourinary System (Genitourinary surgery concentrates on the medical and surgical aspects of the male and female urinary tracts), 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 Resident R22's physician orders, dated June 2, 2023, revealed an order for Ferrous Gluconate Oral Tablet 324 (38 Fe) milligrams, (Ferrous Gluconate), give one tablet, by mouth, in 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, review of facility policy and procedures and interview with staff, it was determined that the facility failed to maintain proper infection control practices related to signage outside of a room for a residen with a transmission based precaution and during tracheostomy care for one of one resident with a tracheostomy. (Resident R109). Findings include: Review of facility policy on Tracheostomy Care dated April 1, 2022 revealed that [NAME] section Policy It is the policy of Bedrock Care to establish standards for the caree and maintenance of tracheostomy tubes. Following these standards will assist in maintaining a patent airway, reduce the risk of nosocomial infection and help to prevent breakdown, excopriation and infection of the surrounding skin. Review of section Procedure reveaed that #4 Equipment, a. Suction equipment, b. Disposable inner cannula, c. Sterile Normal Saline, d. 4X4 gauze, e. Personal protective equipment as needed. Review of facility policy on Transmission Based…

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 interviews with staff, it was determined that the facility failed to maintain a safe, sanitary, and comfortable environment for residents in one of three nursing units. (3rd floor) Findings include: On November 14, 2023, at 10:41 a.m., during observational a tour of the facility in room [ROOM NUMBER] of Resident R91, detected that the sheet rock of the wall was punctured. On November 14, 2023, at 10:46 a.m., during observational a tour of the facility in room [ROOM NUMBER] of Resident R100, detected that the base board molding of the bathroom was peeled off. On November 15, 2023, at 9:37 a.m.during observational a tour of the facility in room [ROOM NUMBER] of Resident R22, detected that the base board molding of the wall was peeled out. At the time of those findings, it was confirmed with a Licensed Nurse, Employee E9. 28 Pa. Code 201.18(b)(1) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews with resident and staff, it was determined that the facility failed to equip corridors with safe handrails, for one of one nursing unit. (3rd floor nursing unit). Findings include: During the observational tour of the facility, on November 14, 2023, at 10:51 a.m., it was detected that the handrail at the corner of the wall, opposite to the elevator on third floor, facing resident room [ROOM NUMBER], the room of R22, was broken, presenting the sharp edges exposed. At the time of the observation, it was confirmed with the Licensed nurse, Employee E9. 28 Pa Code 205.9 (a) Corridors

Based on observation, review of facility policy and interviews with staff, it was determined that the facility did not ensure that hairnets were available and properly utilized in the kitchen during preparation of the luncheon meal. Findings include: Review of facility policy titled Dietary Manual: Dining Services Employees Clothing/ Hygiene/ Hair Guidelines, dated April 1, 2022, revealed that .hairnets and/ or disposable bouffant caps should be stored in an area that is easily accessible to any person entering the department, and hairnets or disposable bouffant caps must cover hair. Observations conducted on September 27, 2023, at 12:05 p.m. in the presence of dietary staff, Employee E3 revealed that during preparation of the luncheon meal, a dietary staff worker was not wearing a hairnet. Dietary staff, Employee E3 approached the tray line with a pan of cooked broccoli. Additionally, Employee E3 working on the line dishing food had his hair improperly secured, with the ends of his braids extending below the line of the net. A hairnet was provided to the surveyor from the pocket of…

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