Deer Meadows Rehabilitation Center

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 a physician assessment was completed related to unplanned weight loss for one of six residents reviewed (Resident R19).Findings include: Review of clinical documentation for Resident R19 revealed that she was admitted to the facility on [DATE] and had diagnoses of dementia (progressive disease of the brain), muscle weakness, dysphagia and Type 2 diabetes (failure of the body to produce insulin). Review of the resident's weight documentation revealed that on August 8, 2025, the resident weighed 132 pounds. The resident was weighed again on September 1 , 2025, and weighed 123.2 which is a -6.67% Loss. The resident was weighed again a month after on October 7, 2025, the resident weighed 121.8 pounds.Review of Resident R19's Weight Warning Note from September 9, 2025 states, Value: 123.2 triggering for significant weight loss -6.7 x1 mo. Please weigh to confirm. Wt. (weight) loss unplanned. Currently…

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

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of three residents observed during medication administration (Resident R137).Findings include:On September 30, 2025, 9:40 a.m., observed that Employee E4, a Licensed Nurse, administered to Resident R137, one tablet of Geri-Dryl Allergy Relief by mouth, and one tablet of Benadryl Allergy Oral Tablet 25 MG (Diphenhydramine HCl), by mouth; along with other medications.On September 30, 2025, 10:20 a.m., review of physician orders for Resident R137 indicated an order dated August 8, 2025, for the following: Benadryl Allergy Oral Tablet 25 MG (Diphenhydramine HCl), Give 1 tablet by mouth. No physician order to administer one tablet of Geri-Dryl Allergy Relief by mouth was available.Review of literature indicated as follows: Geri-Dryl is essentially the same as Benadryl. Geri-Dryl contains 25 mg of diphenhydramine hydrochloride in each tablet, acting as an antihistamine.…

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 Agency regarding a resident fall for one of three residents reviewed for facility reported incidents (Resident R48). Findings Include: Review of facility reported incident, dated January 11, 2025, revealed nurse aide was assisting Resident R48 with evening care. After CNA transferred resident to bed she/he took the wheelchair away from the side of the bed towards the door in resident room to make space for her to assist resident with evening care. Resident was placed at center of the bed. Then suddenly she heard the noise and observed the resident lying on the floor. Upon arrival, the charge nurse observed resident lying on the floor beside her bed. Resident was observed bleeding from her mouth. Resident was then transferred to ER and diagnosed with closed fracture of maxillary bone. Further review of facility reported incident revealed all fall precautions were in place at the time…

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

Based on interview with staff, review of clinical record and review of facility provided documentation, it was determined that facility did not ensure to maintain clinical records in accordance with professional standards of practice for one of three clinical records reviewed. (Resident R2) Findings include:Review of Resident's R2 Minimum Data Set (MDS), completed July 6, 2025, revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated that the resident was cognitively intact.Further review of Resident R2's clinical record revealed a medical diagnosis of chronic obstructive pulmonary disease (COPD), sepsis (blood infection), acute respiratory failure, acute pulmonary edema, and pleural effusion (fluid build up in the lungs).Review of physician orders revealed an order was placed on June 13, 2025, at 3:44 p.m. for vital signs q (every) shift x 30 days, indicating facility time code: 7am - 3pm, 3pm - 11pm, 11pm - 7am. Further review of Resident R2's clinical record revealed no evidence of vital signs were documented on June 14, 2025, during the night shift 11:00…

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 review of clinical records, facility policies and interviews with staff, it was determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice and physician orders, to prevent infection one of 3 residents reviewed for Intravenous Therapy. (Resident R1) Findings include: Review of Facility Policy titled Monitoring and Removal of Midline Catheters and PICC lines revealed at established intervals (upon insertion, upon admission, every 5-7 days during dressing change, PRN (as needed) or per specific facility protocol) document results in medical record. Review of Resident R1's clinical record revealed resident was admitted on [DATE] with a diagnosis of, but not limited to, orthopedic aftercare, local infection of skin, Type 2 Diabetes (failure of the body to produce insulin), and sepsis (infection of the blood). Review of Resident R1's clinical record revealed a physician order dated April 4, 2025, to change PICC line (a thin flexible tube…

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 of the physical environment, interviews with staff and reviews of the pest control operators reports, it was determined that the facility was not maintaining an effective pest control program on one of eight nursing units. Findings include: On March 10, 2025, at 10:06 a.m. observation made on unit [NAME] 1 in the hall roaches killed by unit manger, Employee E3. On March 10, 2025, at 10:10 am interview with unit manger, Employee E3 confirmed concerns related to in the nursing unit. On March 10, 2025, at 10:12 am interview with Resident R5, revealed an observation of many roaches and mice crawling in her room. Observation in resident room roaches baited that were full of roaches. On March 20, 2025, at 11:32 a.m. interview with Resident R6 also reported seeing roaches and bugs in his room. A review of the pest control reports for the past two months revealed the following: On February 7, 2025, go throughout the [NAME] 1 for roaches. On February 25, 2025, reported mice activity 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.

Based on review of clinical record, facility policy, and staff and resident interviews, it was determined that the facility failed to provide medications timely, resulting in significant medication error for one of five residents reviewed (Resident R1). Findings include: Review of facility policy Medication Administration/ Disposition, revised September 2023, revealed medications should be administered in a safe and timely manner, and as prescribed. Facility staff involved in the administration of resident care will be knowledgeable of the policies and procedures regarding pharmacy services including medication administration. Medications, both prescription and non-prescription, shall be administered under the orders of the attending physician or the physician's designee. Further review of facility policy revealed medications must be administered in accordance with the written physician orders, including any required timeframe. Medications must also be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals). May not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical records and facility policies and interviews with staff, it was determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice and physician orders, to promote healing of pressure ulcers and prevent development of pressure ulcers for four of six residents reviewed for pressure ulcer. (Resident 53, Resident R90, Resident R277 and Resident R14) Findings Include: Review of facility policy Wound Management Guidelines revised April 1, 2022, revealed residents will receive the appropriate treatment for their skin issues as identified in the type of skin/wound presentation and the indicated treatment and interventions for the identified issues. Further review of facility policy Wound Management Guidelines revealed the nurse will identify the impairment and stage, if indicated/applicable, based on the skin assessment. The nurse should notify the physician of findings and identify the appropriate treatment and…

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

Based on the review of clinical records, facility investigation, interviews with resident and staff, it was determined that the facility failed to treat residents with respect and dignity related to the right to retain and use personal possessions for one of 35 residents reviewed. (Resident R34) Findings Include: Interview with Resident R34 on November 20, 2024, at 12:15 p.m. stated when he was at the dialysis on November 19, 2024, facility staff searched his room, went through his personal possession, took his over-the-counter medications, and discarded some of the food items that was in the refrigerator in his room without his permission. Resident stated he never had staff search his room or remove his personal possession without permission and he has been a resident of the facility for over on year. Resident stated the search was due to state survey in the facility. Continued interview with Resident R34 stated he called the administrator when he returned from the dialysis and the administrator told the resident that the staff removed medication from his room. Resident also 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews with staff and review of facility policy, it was determined that the facility failed to maintain comfortable and safe temperature levels for one of eight units in the facility ( [NAME] Pavilion Second Floor). Findings include: Review of the facility policy titled, Temperature Extremes last reviewed in November 2021 states it is the policy of the facility to provide comfortable and safe temperature levels. The same policy states, Temperature throughout this facility shall be maintained at between 71 degrees and 81 degrees F. Any temperature outside of this range required specific interventions to avoid potential negative impact on the residents' well-being. On November 19, 2024, at 12:00 p.m. on [NAME] Pavilion Second Floor nursing station the surveyor recognized the unit was uncomfortably warm. Licensed Practical Nurse (LPN) Employee E11 said, This is nothing, it gets even hotter. Interview with the Director of Maintenance, Employee E12 on November 19, 2024, at 12:28 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 review of clinical record, observations, and staff interview it was determined that the facility failed to provide nail care for a dependent resident for one of 35 residents reviewed (Resident R18). Findings Include: Review of Resident R18's annual Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 25, 2024, revealed the resident was cognitively impaired, diagnosed with heart failure, high blood pressure, cerebrovascular accident (Stroke) and dementia. Further review indicated the resident had impairments on both sides of his upper body and was dependent on staff for personal hygiene. Observation of Resident R18 with Licensed Practical Nurse Employee E11 on November 21, 2024, at 10:15 a.m. stated the resident clenches his hands and uses a palm guard because his hands are contracted. The LPN opened Resident R18's hands to reveal his bilateral palms were a deep red color. Further observation revealed the resident fingernails were significantly long and required trimming. The LPN indicated it was difficult to trim his nails short…

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, observations, and staff interview, it was determined that the facility failed to implement fall interventions for two of five residents reviewed for falls (Resident R4 and R110). Findings Include: Facility policy titled Fall Prevention and Management (revised January 2023), indicated that the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents. Clinical record review revealed Resident R4 was admitted to the facility June 28, 2024 with a diagnosis that included but not limited to Acute Respiratory Failure with Hypercapnia (inability of lungs to exchange oxygen and high levels of carbon dioxide properly), Cognitive Communication Deficit (communication difficulty caused by a cognitive impairment), and anxiety disorder. Review of…

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

Based on review of facility policy, observations, review of clinical record, and resident interview, it was determined that the facility failed to monitor and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for one of seven residents reviewed for nutrition (Resident R162). Findings Include: Review of facility Weight Policy revised 04/03/2017, revealed residents should be weighed at least monthly, unless otherwise specified, and that any confirmed weight change should be reported to the physician and registered dietitian for their evaluation and recommendations. Review of Resident R162's care plan revised October 7, 2024, revealed the resident was at risk for alteration in nutrition/hydration. Interventions dated October 7, 2024, included to obtain weights as ordered and monitor PO (by mouth) intake. Review of Resident R162's clinical record revealed a physician note dated November 8, 2024, that the physician was requested by staff to assess Resident R162 for poor appetite. The physician recommended 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 clinical records, review of facility policy, observations, and interview with staff, it was determined that the facility failed to administer oxygen as ordered by the physician for two of four residents receiving oxygen therapy. (Resident R4, Resident R149) Findings include: Review of facility policy Oxygen (revised September 2023), revealed oxygen therapy is to be administered by licensed nurses with a physician's order to provide a resident with sufficient oxygen to their blood and tissues. Clinical record review revealed Resident R4 was admitted to the facility on [DATE], with a diagnosese of Type 2 Diabetes (insufficient production of insulin, causing high blood sugar), Hypertension (high blood pressure), and Hyperthyroidism (thyroid gland makes too much thyroid hormone). Review of Resident R4's physician orders, dated June 1, 2023, revealed that Resident R4 was order oxygen therapy at 2 liters via nasal cannula. Observation on November 19, 2024 at 10:25 a.m. revealed Resident R4's oxygen…

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, interviews with staff and review of facility policy, it was determined that the facility failed to provide culturally competent, trauma informed care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident two of 35 sampled residents (Resident R34 and R106 ). Findings include: A review of the clinical record revealed that Resident R34 was admitted to the facility, with diagnoses of anxiety disorder, major depressive disorder, and post-traumatic stress disorder (PTSD). Review of Resident R34's hospital discharge instructions received on admission, dated June 23, 2023, indicated psychiatry was consulted for reporting black outs in context of PTSD. Prior to this hospital stay, the hospital records reported the resident was hospitalized previously for suicidal ideation, alcohol abuse, depression and PTSD from working as 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 observations and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to the care of urinary catheters and respiratory care equipment for four of 35 residents reviewed. Findings Include: Observation of Resident R135 on November 19, 2024, at 10:32 a.m., revealed that the resident had a urinary catheter. Further observation revealed that the catheter bag was on the floor. Observation of Resident R17 on November 19, 2024, at 10:25 a.m., revealed that resident's oxygen tubing which was connected to oxygen concentrator was lying on the floor without any bag. Observation of Resident R61 on November 19, 2024, at 10:28 a.m., revealed that resident's urinary catheter bag and the tubing was on the floor mats, it was observed that the Nurse Aide who was providing care to the resident was stepping on the floor mat while the catheter tubing and bag was on it. Further observation revealed that there was nebulizer machine and tubing on windowsill. The nebulizer mask and tubing were not bagged, and it was directly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observations, interviews, and review of facility documentation, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for two of eight units in the facility ([NAME] Pavilion first and second floor). Findings include: On November 19, 2024, at 11:33 a.m. surveyor observed a live roach in [NAME] Pavilion second floor nursing station. Licensed Practical Nurse (LPN) Employee E11 said, It happens a lot. The LPN indicated when staff observed pests, they document their findings in the maintenance book. Review of the maintenance book, the LPN stated the last time the area was treated for pest was on October 22, 2024. Further review of the maintenance book revealed documented sightings of roaches and mice on the unit since last treated. On November 21, 2024 at 1:00 p.m. surveyor observed additional pest sightings with Unit Manager, Registered Nurse, Employee E7. Observations on November 19, 2024, at 12:42 p.m. revealed multiple…

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, review of facility policy and interviews with staff, it was determined that the facility failed to maintain essential food service equipment in safe operating condition. Findings Include: Review of facility procedure titled, Resources dated unknown indicates conduct safety and operation inspections 1. Visually inspect all appliances for damage 2. Inspect electric cords and connections 3. Check Filter hoods above stove 4. Check C02 tank storage containers 5. Test functionality of appliances and proper operation of al controls 6. Lubricate per manufacture's specs as needed. 7. Inspect all tethered gas fed appliances. Document findings in log book 1. Remove damaged items from kitchen use 2. Note any discrepancies 3. Note any service repairs and maintenance in TELS equipment log. An initial tour of the main kitchen was conducted on July 25, 2024, at approximately 9:35 a.m. with the Food Service Director (FSD), Employee E3 and Administrator, Employee E1 revealed the main kitchen grill as essential food service equipment had 3…

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 and review of clinical record, it was determined that facility failed to ensure that residents are free of significant medication error related to administration of medications prepared for a different resident. (Resident R1) Findings include: Review of facility's policy 'Medication Administration', reviewed January 2024, indicates that the individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. Checking the identification band b. Checking photograph attached to medical record; and c. If necessary, verifying resident identification with other facility personnel. Further review of policy indicated medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the Director of Nursing Services. Review of Resident R1's clinical record revealed that the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, facility documents, clinical records review, and resident and staff interviews, it was determined that the facility failed to ensure that residents are free of misappropriation of resident property for one out of 10 residents reviewed. (Resident R1). Findings include: Review of facility policy Abuse Prevention last revised October 2020, indicated The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family , friends, etc. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect mistreatment, and/or misappropriation of property. Review of the facility information submitted to the state Survey Agency dated May 15, 2024, indicated that certified nursing aide, Employee E3 misappropriated Resident R1's property by ripped off her magazine picture that were hanging outside 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 review of a meal tray test results, review of facility policy and interviews with resident and staff, it was determined that the facility failed to serve foods that were palatable and at proper temperatures for one of eight nursing floors reviewed. (Ground Wing C) Findings include: Review of facility document Food and Nutrition Services Test Tray and Accuracy Evaluation, revised on January 3, 2024, revealed that the standard temperature for food items as below: Soup- greater than or equal to 135-degree Fahrenheit. Milk- lesser than or equal to 45-degree Fahrenheit. Hot- entrée greater than or equal to 135-degree Fahrenheit. Starch- greater than or equal to 135-degree Fahrenheit. Vegetable- greater than or equal to 135-degree Fahrenheit. Hot Beverages- greater than or equal to 135-degree Fahrenheit. Cold Beverages-lesser than or equal to 45-degree Fahrenheit. Dessert- lesser than or equal to 45-degree Fahrenheit. Review of resident council meeting minute dated April 11, 2024, revealed that the residents complained that the food was bad. They stated that they complained about…

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, review of facility documents, staff and family interview, it was determined that the facility failed to uphold the dignity of two of eight residents (Resident R25 and Resident R85) and during dining service for one of eight nursing unit reviewed. ([NAME] 2 nursing unit) Findings include: Review of the facility document titled Abuse Policy last revised February 8, 2022, revealed verbal abuse is defined as oral, written, or gestured language, that willfully includes disparaging and derogatory terms, to the resident/patient or their families, or within their hearing distance, to describe resident, regardless of their age, ability to comprehend or disability. Continued review of this policy revealed the protocol for any abuse allegations including screening, training, prevention, identification, protection, investigation, employee suspension, reporting to the appropriate agency, and the facility is to ensure that the appropriate corrective, remedial or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interview, it was determined that the facility failed accommodate the residents' needs related to having a bariatric bed and beside chair for 1 out of 35 residents observed. (Resident R41) Findings include: Review of the clinical record revealed that Resident R41 was admitted to the facility on [DATE] , 2023, with diagnosis of Type 2 diabetes (failure of the body to produce insulin), chronic obstructive pulmonary disease (disease process that causes decreased ability of the lungs to perform), end stage renal disease. Review of the Resident R41's Minimum Data Set (MDS- assessment of care needs) dated January 23, 2024, revealed that a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. Review of Resident R41's weight record revealed that the resident weighed on 290.1 pounds on February 10, 2024. On February 12, 2024, at 2:07 p.m. an interview was conducted with Resident R41 who reported that he desires a bigger…

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 interviews, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for residents on one of eight nursing units. ([NAME] 2 Nursing Unit) Findings include: During the initial tour of the [NAME] 2 nursing unit on February 12, 2024, at 11:00 a.m., the following observations were made, -Next to the nurse's station (lower number resident rooms), there was coffee cups, a cup of water and a clear cup on the on the handrail. - There was used socks, trash and food like substance throughout the hallway. -Next to the dining room closet there was trash on the floor appeared like used napkins, sugar packets and food particles on the floor. -Resident room [ROOM NUMBER]A had a bed side table next to the bed which had a black substance on the table which appeared like dried food or drink. -Next to the nurse's station with higher number resident rooms, there was white powder like substance on the floor, - Resident bathroom in room [ROOM NUMBER]A had…

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

Based on, review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to develop comprehensive person-centered care plans related to supervision needs for one out of eight residents reviewed. (Resident R381) Findings include: Review of facility's policy titled Care Planning Process and Care Conference last revised July 3, 2023, revealed facility will develop a comprehensive resident centered care plan for each resident. Care plan development, renewal and revision will be based upon the results of the resident's assessment. The care plan is a working tool that provides a profile of the needs of the individual resident. The care plan will include the initial needs such as adls (activities of daily living), falls, skin tears, nutritional status, behaviors, anticoagulants, psychotropic medication , related to the resident primary diagnosis . The care plan is a working tool that provides a profile of the needs of the individual resident. Further review of this policy revealed that all resident care and interventions must be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews with resident and staff, it was determined that the facility failed to revise the care plan for participation in restorative therapy for one of 35 residents reviewed (Resident R166). Findings include: Review of Resident R166's care plan revealed the resident was admitted to the facility on [DATE], with the diagnoses of high blood pressure and chronic peripheral venous insufficiency (poor circulation of the extremities). Further review of the resident's care plan revealed the resident was on the restorative program to prevent functional decline dated August 31, 2023. Interventions included transferring out of bed to the wheelchair with one person assisting the resident. Interview with Resident R162 on February 14, 2024, at 11:30 a.m. stated she no longer participates in restorative therapy. Interview with the Nursing Home Administrator on February 14, 2024. at 3:30 p.m. confirmed the facility failed to revise and update Resident R166's care plan when the resident no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record, review of facility documents and interview with staff, it was determined that the facility failed to ensure that a physician's orders were followed for two of 35 records reviewed. (Resident R4 and Resident R116) Findings include: Review of the clinical record revealed that Resident R4 was admitted to the facility on [DATE], with a bilateral primary osteoarthritis of knee (degenerative joint disease affecting both knees due to natural wear and tear), disorder of muscle, unspecified atrial fibrillation (irregular heart beat), and congenital deformity of the spine (refers to an abnormality present at birth that affects the structure or alignment of the spine). Review of Resident R4's February 2024 physician orders revealed an order dated February 1, 2024 cleanse RLE (right leg) w (with)/NSS (normal saline solution), pat dry, apply silvedene and calcium alginate, wrap w/kerlex and cover Tubi grip BID (twice a day) and PRN (as needed). On February 12, 2024, at 2:07 p.m. an…

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

Based on observation, review of resident's clinical record, and interview with staff, it was determined that the facility failed to ensure the appropriate supervision related to risk of aspiration for one of eight residents reviewed. (Resident R 381) Findings include: Review of Resident R38'1s clinical record reveal that Resident R381 was admitted in the facility on February 6, 2023, with diagnoses of pneumonia (an infection that inflames the air sacs of one or both lung) COPD (Chronic Obstructive Pulmonary Disease, is an inflammatory lung disease that cause obstructive airflow from the lungs) and dysphagia (a medical term meaning difficulty swallowing which is a symptom of many different medical conditions). Continued review of Resident R 381's clinical record revealed a dietary initial assessment which indicated that there resident was to have a mechanically altered diet consisting of pureed textured foods and thin liquids. Further review of this assessment stated that Resident R381 needed supervision while eating meals. Continued review of Resident R 381's clinical record…

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

Based on observations, review of clinical records and facility policy, and interviews with staff, it was determined that the facility failed to administer oxygen as ordered by the physician for one of 21 residents reviewed. (Resident R104) Finding Include: Observation of Resident R104 on February 12, 2024, at 10:42 a.m, revealed that the resident was receiving oxygen via nasal cannula from a portable oxygen concentrator (machine). The oxygen was set at 4 liters per minute. This was verified by Employee E2, Registered Nurse Unit Manager. Review of physician orders for Resident R104 on April 16, 2023, revealed an order to administer oxygen at 2 liters per minute via nasal cannula continuously. Interview with Employee E12, on February 12, 2024, at 10:42 a.m. confirmed that the resident was receiving oxygen at 4 liters per minute and the resident should be receiving oxygen at 2 liters per minute. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to provide appropriately textured foods to meet the needs of residents on a mechanically altered diet for one of 22 residents observed during dining (Resident R158). Findings Include: Review of the clear liquid diet guidelines from the facility's diet manual revealed the diet consists of foods that are clear and liquid, or that becomes liquids at room or body temperature. The diet contains no milk or milk products. Review of Resident R158's physician order dated January 25, 2024, revealed the resident was ordered a clear liquid diet. Continued review of Resident R158's physician orders revealed an order dated October 15, 2023, to provide a pureed snack at bedtime. Review of Resident R158's administration record for November 2023 through February 2024 revealed the resident was routinely offered the nighttime pureed snack with 50-100% consumption. Review of Resident R158's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure foods were stored in accordance with food safety standards for one of eight nursing unit pantry's ([NAME] 1). Findings Include: Review of facility policy Pantry Refrigerator, revised September 2021, revealed pantry refrigerators will be monitored on a routine basis to ensure food safety. Refrigerator temperatures will be maintained at 32 to 41 degrees Fahrenheit and freezer temperatures will be maintained at 0 to less than or equal to -10 degrees Fahrenheit. Further review of facility policy revealed refrigerators will be checked on a routine basis for cleanliness and cleaned monthly or as needed. Review of facility policy Food from Home, revised July 2017, revealed it is the policy of the facility to provide safe and sanitary storage and handling of all food including food brought to residents by family and other visitors. Further review of facility policy revealed foods requiring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews with resident and staff, review of clinical records and facility policy, it was determined that the facility failed to ensure one resident who concent to received the Covid -19 vaccine was provided the vaccine in a timely manner for one of 35 resident records reviewed (Resident R166). Findings include: Review of the facility's policy for Covid-19 vaccines and booster vaccines revised in [DATE] stated all vaccines shall be offered to residents unless the vaccine is medically contraindicated, to encourage and promote the benefits associated with vaccinations against Covid-19 by minimizing the risk of acquiring, transmitting or experiencing complications from the Corona virus. The policy continues to state that residents who received the vaccine will have the vaccine administration documented in the resident's Vaccine Administration Record (VAR) . Review of Resident R166's clinical record revealed the resident was admitted to the facility on [DATE], diagnosed with high blood pressure and chronic…

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 resident and staff, it was determined that the facility failed to ensure a safe sanitary and functional environment for one resident and four resident rooms of two floors (Second floor dining room and First Floor Rehab). Finding Include: Interview with Resident R116 on February 12, 2024, at 10:27 a.m. stated his wheelchair leg rest was broke and part of the leg rest was missing foot pad. He stated it was like that for almost four months. Observation of Resident R116's wheelchair revealed that the left side leg rest was missing foot pad which exposed sharp metal edges. Wheelchair also had white color substance underneath the seat on the metal frame appeared like dust and cobb [NAME]. Observation of resident rooms 208, 209 and 210 revealed that there was window air-condition unit on the windowsills. There was wash cloths and towels around the air conditioning unit. Interview with Resident R116 on February 12, 2024, at 11:00 a.m., stated he was keeping the towel to prevent…

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.