Immaculatemarycenter For Rehabilitation&healthcare

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 failed to ensure that an elopement risk assessment was accurate for one of 13 residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed that the resident was admitted on [DATE] with a diagnosis of dementia (loss of cognitive functioning that interferes with daily life and activities), muscle weakness, and major depressive disorder. Review of Resident R1's care plan, dated September 24, 2025, revealed the resident has impaired cognitive function related to dementia. Review of Resident R1's elopement evaluation, dated September 23, 2025, revealed the resident was not at risk for elopement. Further review of the same elopement assessment it was noted the assessment was inaccurately coded and indicated the resident was not cognitively impaired or had a diagnosis of dementia. Interview on October 03, 2025 at 11:15 a.m. with Employee E4, Licensed Practical Nurse, confirmed the…

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

Based on the review of clinical records, podiatry consults reports and interviews with staff, it was determined that the facility failed to implement podiatry recommendation for wound care and promote wound healing for one of five residents reviewed. (Resident R1)Findings Include:According to National Library of Medicine Chronic wounds often occur in patients with diabetes mellitus due to the impairment of wound healing. Impaired healing in diabetes is the result of a complex pathophysiology involving vascular, neuropathic, immune, and biochemical components. Hyperglycemia correlates with stiffer blood vessels which cause slower circulation and microvascular dysfunction, causing reduced tissue oxygenation. Blood vessel alterations observed in diabetic patients also account for reduced leukocyte migration into the wound, which becomes more vulnerable to infections. The hyperglycemic environment itself can compromise leucocyte function. In addition, peripheral neuropathy can lead to numbness of the area and reduced ability to feel pain, which can lead to chronicization of wounds that…

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

Based on the review of clinical records, observations, and interviews with resident representative and staff, it was revealed that the facility failed to provide appropriate services to promote and maintain hearing abilities for one of five residents reviewed. (Resident R3)Findings Include:Review of Resident R3's MDS (Minimum Data Set-Assessment of resident care needs) dated February 28, revealed that resident's ability to hear had moderate difficulty and Resident R3 was using a hearing aide.Review of Resident R3's MDS (Minimum Data Set-Assessment of resident care needs) dated February 28, revealed that resident's ability to hear had moderate difficulty and Resident R3 was using a hearing aide.Interview with Resident R2's representative on September 15, 2025, at 10.50 a.m. revealed that the resident had difficulty hearing and she was missing her hearing aid. Resident R5 was not using a hearing aid when she was admitted to the facility however a week after her admission the hearing aid was missing. Resident representative said the resident was not seen by an audiologist or the…

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

Based on clinical record review and staff interviews, the facility failed to ensure that a physician assessment was completed and that changes in medical status were addressed in accordance with professional standards of practice for diabetic management to promote wound healing for one of five residents reviewed (Resident R1).Findings Include:According to the National Library of Medicine, Chronic wounds often occur in patients with diabetes mellitus due to the impairment of wound healing. Impaired healing in diabetes is the result of a complex pathophysiology involving vascular, neuropathic, immune, and biochemical components. Hyperglycemia correlates with stiffer blood vessels which cause slower circulation and microvascular dysfunction, resulting in reduced tissue oxygenation. Blood vessel alterations observed in diabetic patients also account for reduced leukocyte migration into the wound, making it more vulnerable to infections. The hyperglycemic environment itself can compromise leukocyte function. In addition, peripheral neuropathy can lead to numbness of the area and reduced…

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.

Findings Include:Review of facility policy Enhanced Barrier Precautions dated September 2024 revealed that Enhanced barrier precautions (EBP) utilizes targeted gown and glove use during high-contact resident care activities to reduce the transmission of MDRO's(Multi drug Resistant organisms). Examples of high contact resident care activities requiring gown and gloves for EBP include but are not limited to Dressing, Wound care: any skin opening requiring a dressing.According to CDC (Centers for Disease Control and Prevention) guidelines Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings revealed that Wound care supplies such as dressing materials and equipment should be selected and gathered prior to entering the patient/resident care area to avoid accessing the supply cart/clean storage area during the procedure. Only the materials needed for an individual patient/resident should be brought into the patient/resident's room or treatment area and placed on a clean surface and away from potential sources 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 review of clinical record, facility documentation, and interviews with staff, it was determined that the facility failed to report an injury of unknown origin to the local State Survey Agency as required for one of four resident records reviewed (Resident R1).Findings include:Review of facility policy Abuse Prevention/Reporting, revised 2023, revealed Staff is trained upon orientation and annually on the abuse prevention program. The training will include types of abuse, stress management tips, and the recognition of signs and symptoms of abuse which may include, but are not limited to the following:a. bruises, skin tears, welts, etc., of unknown origin;b. unexplained injuries.The facility will report all alleged violations involving mistreatment, neglect or abuse to the Department of Health, Division of Nursing Facilities, and to other agencies required by law and Act 13 (Ombudsman. Police, Department, Department of Aging Services, Protective Services). The facility will conduct an investigation of 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 observation and interview with staff, it was determined that facility did not ensure to provide a safe, clean, sanitary and homelike environment for five of 51 rooms observed (Room#'s 200-B, 207-B, 209-B, 210-B, 425-B) Findings include: Review of facility policy 'Homelike Environment,' indicates that residents are to be provided with a safe, clean, comfortable and homelike environment Observations on 2nd floor unit, on Monday, April 14, 2025 at 10:30 am, in room [ROOM NUMBER]-B, revealed two used wash cloths on floor in front of resident's bed, unemptied trash bin, and unemptied bed side commode. Further observations in room [ROOM NUMBER]-B, at 11:00 am, revealed overflowing trash bin as well as excess trash on floor, three separate liquid areas on floor. Upon interview with nurse aide, employee E4, it was revealed that staff from previous shift were responsible for cleaning room [ROOM NUMBER]-B. Further observations of 2nd floor unit, revealed amount of trash under bed in room [ROOM NUMBER]-B. Further…

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 refer a resident with a newly diagnosed mental disorder for level II of the PASRR (Pennsylvania Pre-admission Screening Resident Review) or three of three residents reviewed (Residents R119, R174, and R184). Findings include: The PASRR (Pennsylvania Pre-admission Screening Resident Review), federally required form to help ensure that all individuals are evaluated for serious mental disorder and/or intellectual disability to ensure applicants are not inappropriately placed in nursing homes for long term care, dated March 1, 2009, lists examples of serious mental illness including mood disorder, bipolar, and depression. The revised PA-PASRR-ID bulletin number dated March 1, 2014, revealed that nursing facilities are responsible for assuring the accuracy of information reported on the PA-PASRR-ID form. If the individual has a change in condition that affects target status a PA-PASRR-EV (Level II) will need to 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 observations of care and services, interviews with staff, reviews of clinical records and policy and procedures, it was determined that the facility failed to develop a comprehensive care plan for oxygen therapy and antipsychotic medication for two out of 35 residents reviewed. (Resident R41 and R190) Findings include: A review of the policy titled Resident Plan of Care dated June 2024, revealed Our facility's Care Planning/Interdisciplinary Team is responsible for the development of a plan of care for each resident. The care plan is based on the resident's assessment and is developed by a Care Plan/Disciplinary Team. A review of a clinical record for Resident R41 revealed an admission on [DATE], with chronic obstructive pulmonary disease (disease process that causes decreased ability of the lungs to perform) and polyneuropathy (a general degeneration of peripheral nerves that spreads toward the center of the body). A review of the physician order dated October 25, 2024, revealed an order for oxygen 2…

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, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store food in accordance with professional standards for food service safety. Facility Policy: The review of the facility's policy titled Food Storage, dated March 2020 revealed Foods shall be stored in a manner that complies with safe food handling practices. Under fourth sentence All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). On April 14, 2025, at 9:23 a.m., a kitchen tour was conducted with the Dietary Supervisor, Employee E10. During the tour, it was observed that the preparation table contained various spices-such as ground cinnamon, chicken herb, Italian seasoning, and poultry seasoning-that were opened and not dated. Additionally, an opened container of [NAME] Parmesan cheese was found stored alongside the spices without a label or date. According to Employee E10, the manufacturer's instructions indicate that Parmesan cheese…

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

Based on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Finding includes: A tour of the Food Service Department was conducted on April 14, 2025, at 9:23 a.m., with the Dietary Supervisor, Employee E10. The following concerns were noted: A 96-gallon commercial trash can was observed leaking a significant amount of yellow and brown liquid as staff transferred it from the dishwasher area to the loading dock. Employee E10 stated that the Administrator had been notified of the issue several weeks ago and that a replacement trash can had been ordered. Two staff members were observed outside cleaning the cement near the dumpster due to residue from the leaking trash can. On April 15, 2025, at 9:25 a.m., further observations revealed ongoing issues. Two 96-gallon commercial trash cans were actively leaking. One can, located near the dishwasher, was in use while staff scraped dirty plates from breakfast trays. A trail of spilled food-including string beans, peas, and chopped carrots-was observed…

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

Based on observation, review of facility policy and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with appropriate cleaning techniques for medical equipment, on two of the four Medication Administration Reviews; (R106, R96) and Enhanced Barrier Precautions for three of four residents during wound treatment (Residents R96, R113, and R539). Findings include: Review of Facility Policy effective date September 2024, on Enhanced Barrier Precaution, indicated that Enhanced Barrier Precautions are infection control intervention designed to reduce the transmission of novel or Multi-Drug-Resistant Organisms (MDROs). Enhanced Barrier Precautions require to employ the use of targeted Personal Protective Equipment (PPE) during high contact patient/resident activities. It utilizes targeted gown and glove use during high-contact resident care activities to reduce the transmission of MDROs. Further review of policy points out examples of high - contact resident care activities requiring gown and gloves 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 observation and review of facility policy, it was determined facility did not ensure dignity for one of two residents during wound care treatment (Resident R207) Findings include: Review of facility policy 'Resident Dignity,' indicates that staff shall attempt to maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Review of Resident R207's clinical record revealed a medical history of unspecified intellectual disabilities, non-pressure chronic ulcer of back limited to breakdown of skin, muscle wasting and atrophy, orthostatic hypotension, heart failure. Review of R207's care plan, revealed that resident is to be encouraged to allow bed to be in the lowest position when care is not being provided. During hygiene care and wound care treatment on Wednesday, April 16, 2025 at 11:30 am, room [ROOM NUMBER]-B, observed both nursing employees - nurse aide, employee E8 and licensed nurse, employee E7 - leave the room at the same…

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 the facility policies and procedures, review of clinical records, and interview with staff, it was determined that the facility failed to implement treatment and services for incontinence management for one of 24 residents reviewed (Resident R88). Findings include: Review of literature revealed that, a Foley catheter is a thin, flexible tube inserted into the urinary bladder through the urethra (the urethra is a tube that carries urine from the bladder out of the body in both males and females) to drain urine. It's used for various reasons, including urinary retention, bladder drainage during surgeries, and when someone cannot urinate on their own. The catheter is held in place by a small balloon filled with water inside the urinary bladder. The French scale is a universal system for sizing Foley Catheters, by measuring its external diameter. In medical terms, Foley size Fr refers to the French scale used to measure the diameter of a Foley catheter. Each French unit (Fr) is equivalent to 0.33 millimeters (mm) in diameter. Choosing the correct size of Foley…

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 policies and procedures, observations of care and services, and interviews with staff, it was determined that the facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for two of 35 residents reviewed. (Resident R41 and R57). Findings included: A review of the facility policy titled Oxygen Administration-Resident dated March 2020, stated The purpose of this procedure is to provide guidelines for safe oxygen administration. Bulletin # 6 further stated Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen at the rate ordered. A review of a clinical record for Resident R41 revealed an admission on [DATE], with chronic obstructive pulmonary disease and polyneuropathy. Review of Resident R41 physician orders revealed an order obtained October 25, 2024, for oxygen 2 liter via N/C (per min via nasal cannula), every shift diagnosis of pneumonia. On April 15, 2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address a resident's dementia care needs for one of 35 residents reviewed (Resident R169). Findings Include: Review of the admission sheet of Resident R169, revealed that Resident R169 was admitted to the facility on [DATE], with the diagnosis of Dementia (Dementia is not a specific disease but is rather a general term for the impaired ability to remember think, or make decisions that interferes with doing everyday activities). Review the care plan date March 13, 2025, revealed that of Resident 169's care plan revealed no care plan with measurable goals and interventions to address the care and treatment need related with dementia care of Resident R169. During an interview on April 16, 2025, at 12:10 p.m., the Director of Nursing (DON), confirmed that residents with diagnosis Dementia should be care planned. 28 Pa Code 211.11(d) Resident care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, and interviews with residents and staff, it was determined that the facility failed to maintain personal dignity for five of five residents observed (Resident R1, R2, R3, R4, R5). Findings: Facility policy titled Resident Dignity, dated 2020, revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents' private space and property shall be respected. Staff shall maintain an environment in which private information is protected. Staff shall attempt to maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed. Clinical record review revealed Resident R1 was admitted to the facility on [DATE] with a diagnosis of fracture of upper end of left humerus (arm), chronic kidney…

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 interviews, it was determined that the facility failed to offer and or provide the influenza and pneumococcal immunization for 10 of ten residents reviewed. (Resident R 15, R36, R39.R 73, R110, R111, R190, R204, R228, R231). Findings include: Review of facility policy titled Influenza vaccine dated November 2018 revealed that all residents who have no medical contradictions to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccination against influenza. Further review of this document revealed that for those residents who receive the vaccine, the date of vaccination, the lot number, expiration date, person administrating, and site of vaccination will be documented in the residents medical record. A resident's refusal shall be documented in the resident medical record. Review of the The Advisory Committee on Immunization Practices (ACIP) refers to a group of medical and public health experts that develops…

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, interviews and the review of clinical record, it was determined that the facility failed to ensure that 1 out of 37 residents was assessed to ensure that it was clinically appropriate to self-administer medication (Resident R606). Findings include: Review of the facility policy, Self-Administration of Medication, with an effective date of 11/2017 indicated that the resident's mental and physical abilities will be assessed to determine whether self-administering medication is clinically appropriate for them to do so, in addition to other assessment factors that include, but not limited to the resident's ability to read and understand medication labels, the resident's comprehension of the purpose, proper dosage, the administration time for the medication(s), and the resident's comprehension of the purpose and proper dosage and administration time for his or her medications. Continued review of the policy indicated that self-administered medications must be stored in a safe and secure place in the resident's room, in a medication cart, or in the facility'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 interviews and review of clinical records, it was determined that the facility failed to ensure that written notice, including the reason for the room change was provided to the resident and/his or her responsible party prior to the room change for 1 out of 37 residents reviewed (Resident R609). Findings include: Review of the facility's policy Room Changes, with a revision date of October 2022 indicated that when a resident request a room change, they will be offered another appropriate bed, as available. The policy also stated that before the room change occurs, the resident and their roommate will be notified of the reason for the room change. Review of the Resident R606's June 2024 physician orders included the following diagnosis: aortic aneurism (a bulge in the wall of an individual's aorta that can rupture or dissect and cause life-threatening bleeding), hypertension (high blood pressure); epilepsy (a brain condition that causes recurring seizures) and glaucoma (a condition in which the never that provides information to the brain is damaged and will cause gradual…

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 and review clinical records it was determined that the facility failed to ensure that the physician was notified of a resident's refusal to take prescribed medications for one of 46 residents reviewed (Resident R108). Findings Include: Review of the facility policy titled Administering Medications, effective March 2020, states medications shall be administered in a safe and timely manner, and as prescribed. Review of Resident R108's Quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 31, 2024, revealed the resident was cognitively intact, had a diagnosis of diabetes mellitus (characterized by high blood sugar levels in the blood - a disorder in which the body does not produce or appropriately utilize insulin in the body) and received insulin (hormone produced by the body which regulates the amount of glucose in the blood) injections. Review of Resident R108's comprehensive care plan revised October 6, 2022, revealed the resident had potential for hyperglycemia related to a diagnosis of diabetes,…

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, resident interviews, and staff interviews, it was determined the facility failed to ensure that resident care plans were reviewed and revised to reflect the residents' status and care needs related to communication and aggressive behavior for two of eights residents reviewed. (Resident R507 and R205) Findings include: Review of the facility policy Comprehensive Care Plan dated March 2020, revealed A plan of care will be created for each resident that includes but not limited to measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. Continued review of this policy revealed that Identifying problem areas and their causes, and developing interventions, that are targeted and meaningful to the resident, are the endpoints of the interdisciplinary process. The Assessments of the residents are ongoing and care plans are revised as information about the residents and residents condition changes. Review of Resident R507's Quarterly minimum data set (MDS- a federal mandated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and the review of clinical records, it was determined that the facility failed to maintain acceptable parameters of nutritional status related to a resident's recorded weights for 1 out of 37 residents (Resident R112). Findings include: Review of the policy, Resident Weights, with an effective date of March 2020 indicated that the nursing staff will measure resident weights upon admission and record the weights in each resident's electronic record. The policy also indicated that weight changes of 5% or more will be retained, and if the weight is verified, nursing will notify the dietician. Continued review of the policy indicated that the dietician wil review resident weights monthly to follow individual weight trends over time. The policy also indicated that negative trends will be evaluated by the treatment teams as to whether or not the criteria for significant weight change has been met. Review of the June 2024 physician orders for Resident R112 indicated that the resident was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records and interviews with residents and staff, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice, for one of 37 residents reviewed (R71). Findings include: Review of facility policy, Administering Medications dated March 2020 revealed, Medications must be administered one hour before and after the prescribed times. Interview on June 17, 2024, at 10:07a.m. Resident R71 stated that her pain medications were not received this morning and that she was in a lot of back pain. Review of Resident R71's record revealed that she was admitted to the facility on [DATE], with diagnoses including low back pain, infection, and inflammatory reaction due to other cardiac and vascular devices. Review Resident R71 physician order on June 17, 2024, at 10:10 am revealed order on May 23, 2024, Gabapentin oral capsule give 100 mg by mouth three times (9am, 1pm and 5pm) a day for pain.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of 37 dialysis residents reviewed (Resident R71). Findings include: Review of Resident R71's clinical record revealed that the resident was admitted to the facility on [DATE], and has a diagnosis of 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 R71's physician order, dated May 24, 2024, revealed that Resident R71 receive dialysis treatment in the facility on Monday through Friday. Review of Resident R71's Hemodialysis Communication Record revealed that on, May 24, 2024, through June 14, 2024 it didn't have information on Pre-Weight before going to dialysis. On each of the communication record the top part say nursing home use only prior 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 interviews and the review of clinical records it was determined that that facility failed to ensure that behavioral health services were provided to 1 out of 37 residents who stated that she wanted to die (Resident R606). Findings include: Review of the Resident R606's June 2024 physician orders included the following diagnosis: aortic aneurism (a bulge in the wall of an individual's aorta that can rupture or dissect and cause life-threatening bleeding, hypertension (high blood pressure); epilepsy (a brain condition that causes recurring seizures) and glaucoma (a condition in which the never that provides information to the brain is damaged and will cause gradual vision loss if not treated). Review of a nursing note dated May 28, 2024, at 1:40 a.m. indicated that the resident complained of chest pain was provided with 3 tablets of Nitrostat (tablets used to relieve chest pain) administered but provided no relief to the resident. Emergency Medical Services were contacted, but when they arrived, the resident refused to go and stated that she wanted to die: Resident refused 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policy and staff interview determined the facility failed to ensure one of 37 residents reviewed was free from a significant medication error (Resident R174). Findings include: Review of the facility policy titled Administering Medications, effective March 2020 states medications shall be administered in a safe and timely manner, and as prescribed. The individual administering the medication must check for the following five rights of administering medications: a. Right Resident b. Right time and frequency of administration c. Right Dose d. Right Route e. Right Drug Resident R174 was admitted to the facility on [DATE], diagnosed with Diabetes Mellitus (the body cannot regulate and use sugar as fuel), high blood pressure and unspecified intellectual disabilities. Review of Resident R174 Nursing progress note dated, May 7, 2024, stated at 10:50 a.m. Resident R174 received her roommate's medications in error. The medications that were given to Resident R174 were,…

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 and the review of clinical records, it was determined that the facility failed to ensure complete and accurate clinical records for 1 out of 37 records reviewed (Resident R98). Findings include: Review of the January 2024 physician orders for Resident R98 included the following diagnosis: diabetes (a condition that happens when your blood sugar is too high); absence of left leg below the knee and absence of right toes; hypertension (high blood pressure) and dependence of renal dialysis ( the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Continued review of the resident's June 2024 physician orders included a physician's order dated September 29, 2023 for the resident to attend dialysis treatment 5 days. The resident's start time for dialysis treatment was listed as 8:15 a.m. Review of nurse documentation on October 9, 2024 at 12:10 p.m. by Employee E12 (licensed nurse) indicated that the resident returned from in house dialysis due to being hypotensive (low blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, review of clinical records, review of facility documents, and staff interviews it was determined that the facility failed to maintain an effective pest control program in the main kitchen, laundry, and one resident room. Findings Include: Review of pest control report dated February 19, 2024, revealed the kitchen is seeing roaches . a lot of roach activity behind the wall covering by the steamers . recommended a clean out. The administration would like to try conventional treatments first. Review of pest control report dated February 22, 2024, revealed the kitchen was treated for roach activity. Review of pest control report dated May 8, 2024, revealed the pest control company met with the Nursing Home Administrator, Employee E1, and the dietary manager to discuss roaches in kitchen oven. Oven was opened and bait was applied to the inside of the oven. Review of pest control report dated May 15, 2024, revealed laundry was treated for roach activity. Review of pest…

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 interview, it was determined that the facility failed to provide a clean and homelike environment to on one of two nursing units (Third Floor Nursing Unit). Findings include: Observation of the Third Floor Nursing Unit designated as 3-North revealed the following: On May 16, 2024, at approximately 11:00 a.m., a strong odor of urine was detected near room [ROOM NUMBER] while touring the nursing unit. Follow up observation was conducted on May 16, 2024 at 2:10 p.m. with the Nursing Home Administrator a strong urine odor was still noticeable near room [ROOM NUMBER]. The Nursing Home Administrator confirming that the odor of urine was present.

Based on the review of clinical records, facility documentation, facility policies, and interviews with resident and staff, it was determined that the facility failed to demonstrate evidence that a resident/resident representative grievance was promptly documented, and resolved for one of three resident records reviewed and failed to ensure that the grievance policy inlcuded all the required components. (Resident R1) Findings Include: Review of facility policy Grievance/Concern Recording and Investigation revised 09/2023 revealed Grievances/concerns filed with the facility will be investigated and actions will be taken to resolve the grievance/concerns. Policy Interpretation and Implementation: The Administrator has assigned the responsibility of investigating grievances/concerns to the department director or designee. Upon receiving a grievance/concern report, the department director or designee will begin an investigation into the grievance/concern. If the grievance/concern cannot be addressed timely, a written grievance/ concern will be documented on a concern log for further…

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's policies, review of clinical records and staff interviews, it was determined that the facility failed to ensure that an alleged violations involving resident neglect was reported to the State Survey Agency (Department of Health) as required for two of three residents reviewed (Resident R1 and Resident R2). Findings include: Review of the facility policy titled, Abuse Prevention/Reporting revised, December 12, 2023, revealed, Neglect - the failure of a facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. ABUSE means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause…

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, facility policies and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation of improper resident care for one of three residents reviewed. (Resident R2). Findings include: Review of the facility policy titled, Abuse Prevention/Reporting revised, December 12, 2023, revealed, Neglect - the failure of a facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. ABUSE means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, physical abuse, 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.