Independence Rehab and Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, facility policy, resident and staff interviews, it was determined that the facility failed to maintain the facility in a safe, clean and homelike condition on two of four nursing units (1st floor [NAME] Unit and 4rth floor nursing unit). Findings: A review of the facility policy titled Policy Number: RR1.01 revised 09/2025 stated under bulletin 3. gg. Section p.8 F584 Safe/Clean/Comfortable/Homelike Environment- 1. Right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely. 2. Housekeeping and maintenance services that maintain a sanitary, orderly, and comfortable interior 3. Clean bed and bath linens that are in good condition 4. Private closet space in each resident room [ROOM NUMBER]. Adequate and comfortable lighting levels in all areas, comfortable and safe temperatures levels (71F-81F), and maintenance of comfortable sound levels. On January 21, 2026, at 9:30 a.m., an observation on the…

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

Based on observations and interviews, it was determined that the facility failed to ensure complete and accurate clinical record regarding the consumption of a meal for 1 out of 3 residents observed (Resident R5).Findings include:Review of the January 2025 physician orders for Resident R5 included the following diagnosis: kidney failure (a condition in which one or both of your kidneys no longer work on their own); osteoporosis; psychosis (the term for a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not), and post-traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it).Review of a physician's order for Resident R5 with an order date of August 25, 2022 and monthly thereafter included an order for the resident to have a fortified cereal one time a day during her breakfast meal for the additional calories and protein intake. Fortified Cereal one time a day for additional kcal and protein intake. With breakfast. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical record review, and interviews with resident and staff, it was determined that the facility failed to assist and initiate a discharge plan for a resident who requested to be discharge from the facility for one of three residents reviewed. (Resident R1) Findings include:Review of the facility policy title Discharges dated October 1, 2025, revealed that the residents may not be discharged unless specific criteria are met and at the facility must provide written notice, physician documentation, and coordinate discharge planning with social services, nursing, MDS (resident assessment of care needs), and therapy. The policy requires a discharge notice include the reason for discharge, effective date, appeal rights, and discharge location, and that a post discharge plan of care be developed. Review of Resident R1's admission MDS dated [DATE], revealed that this resident was admitted into the facility on October 8, 2025. Resident R1 was assessed with a BIMS (Brief interview…

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

Based on observations, review of facility policy, and interview with residents and staff it was determined that the facility failed to ensure that residents were explained their resident rights for four of eleven residents reviewed. (R1, R76, R120, and R178). Findings Include:Review of the facility policy titled Resident Rights undated, reads Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility will also provide the resident with prompt notice (if any) of changes in any State or Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing. Further review of the Resident Rights policy revealed, Policy Explanation and Compliance Guidelines: A posting of names, addresses and phone numbers of all pertinent state client advocacy groups will be available in the facility.During…

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, facility policy review, and staff interview, it was determined that the facility failed to provide residents with the ability to file grievances anonymously for four out of four nursing units reviewed.Findings Include: Review of the facility policy titled, Grievance Policy dated November 2016 states, The facilities established grievance policy includes: Notifying the resident individually or through posting of the right to file grievances orally or in writing, the right to file grievances anonymously, the contact information of the grievance official, a reasonable expected time frame for completing review of the grievance, the right to obtain a written decision, the contact of independent entities to whom grievances may be filed (state agency, quality improvement or, state survey agency, state LTC ombudsman). Further review of the facility policy states, The facility Grievance Office is the Social Worker, and is responsible for: Overseeing the grievance process, receiving and tracking grievances to conclusion, leading any necessary investigations, maintaining…

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, and interview with staff it was determined that the facility did not notify the state mental health authority or state intellectual disability authority, promptly after a significant change in the mental condition for three of thirty-three residents reviewed. (R4, R53, R56).Findings Include: Review of Resident R4's psychiatry note from September 2, 2025 stated, [Resident R4] with noted history of schizoaffective disorder in electronic health records system and past psychology note. Resident R4 does not answer appropriately assessment questions and is a poor historian. [Resident R4] was previously prescribed Haldol, but medication was discontinued in 2024, after discontinuation, pt displayed no signs of psychosis. [Resident R4's] medical record includes no documentation confirming schizoaffective diagnosis. This patient does not meet DSM-5 criteria for schizoaffective please remove diagnosis. Continued review of the resident's record revealed no further communication with the state mental health authority. Review of Resident R53's psychiatry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical record, review of facility policy and interview with staff, it was determined that the facility failed to ensure that a person-centered care plan was developed related to oxygen and PTSD (post-traumatic stress disorder) for two of 33 residents reviewed (Resident R11 and Resident R19) Review of facility's undated policy on Comprehensive Care Plan revealed that under section Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Section Policy Explanation and Compliance Guidelines:1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services…

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 policy and interview with staff, it was determined that the facility failed to provide timely pressure ulcer treatment for one of nine residents reviewed (Resident R13). Review of Resident R13's clinical record revealed that Resident R13 was admitted to the facility on [DATE], with diagnoses of but not limited to Hypertension (high blood pressure), Rheumatoid Arthritis (isa chronic autoimmune disease that primarily affects the joints), Hypothyroidism (condition due to deficiency in the thyroid hormone resulting in decreased body metabolism).Review of Resident R13's MDS (minimum data set a federally required resident assessment completed at a specific interval) dated June 26, 2025, revealed that section GG0130. Self-Care C. Toileting hygiene: was coded has dependentant.Review of nurse's aide task revealed that for toileting and hygiene Resident R13 was dependent to maximum assist.Review of Resident R13's nursing note dated July 25, 2025, reveal that Nurse'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 observations, review of facility documentation, and staff interviews, it was determined that the facility failed to ensure that hot beverages were served at a safe temperature during a resident activity in one of four floors. (Second floor dining room) Findings include:The FDA, Consumer Product Safety Commission, and the American Burn Association all warn against serving beverages at temperatures above 150 F, as liquids at or above this level can cause severe burns within seconds. According to these organizations, a serious burn can occur in just one second when a beverage is served at 160 F. To minimize the risk of scalding injuries, best practices recommend that hot beverages be served at temperatures between 130 F and 160 F.Review of The American Burn Association https://ameriburn.org, revealed at 140 degrees Fahrenheit, serious burns can occur in about five seconds and a 160 degrees Fahrenheit it can happen in just one second, this underscores how quickly severe burns can occur from hot liquidsObservation on n September 15, 2025, at approximately 11:00 AM, during 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 clinical record review and staff interview, the facility did not ensure that nurse aides received annual performance evaluations to assess competency and performance, as required. Findings Include: An interview was held on September 17, 2025 at 2:45 p.m. with Employee E1 the Nursing Home Administrator. Employee E1 when asked to provide evidence nurse aides were evaluated at least every 12 months. Employee E1 stated, we don't have any nurse aide evaluations. I thought that they needed the required trainings only. Based on the information above, the facility could not provide any nurse aide evaluations during the past 12 months. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(c) Nursing services

Based on observation, review of facility documentation and staff interview, it was determined that the facility failed to ensure that dietary equipment to maintain hot foods remain in functional capacity. Findings include: Observations of the food and nutrition services department on September 15, 2025 at 11:30 a.m., in the presence of the food service director, Employee E7, revealed that the plate warmer was not equipped with a lid/cover that was necessary to contain heat. This piece of foodservice equipment was designed to warm/heat the ceramic plates that were used for plating and serving meals to the residents. The ceramic plates were not hot to touch. Additional observations of the food and nutrition services department on September 15, 2025, revealed that the dietary operation was not using a complete thermal system for maintaining hot foods (meals) during transportation and delivery to the nursing units from the main kitchen. Interview with the Director of Dietary Services at 11:30 a.m., on September 15, 2025, revealed that the thermal pellet base charger and thermal pellet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, interviews with staff and reviews of policies and procedures, it was determined that the Nursing Home Administrator and Director of Nursing effectively and efficiently implemented resources to management incidents of resident abuse and failed to ensure that behavior management resources were implemented for one of seven sampled residents (Residents R148) Findings include:A review of the facility policy titled accident and incident-investigation, and reporting dated July 2017 revealed that all accidents and incidents involving residents occurring on the premises were to be investigated and reported to administration. The nursing supervisor was required to document and investigate the accident and incident. The report was to contain the circumstances surrounding the accident and incident, names of all parties involved such as witnesses and their accounts of the accident or incident, residents' statements of the event, the physician's response to the event was to be documented,…

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 record review, facility policy review, and staff interviews, the facility failed to develop and maintain an accurate, comprehensive facility-wide assessment. Findings include:Review of the facility's policy titled Facility Assessment (dated 2025) revealed that the facility is required to complete and document a comprehensive facility-wide assessment to determine the resources necessary to care for residents competently during both routine operations and emergencies. The policy identifies that the facility assessment must include, at a minimum:- The resident population, including number, facility capacity, and care needs using data-driven methods that reflect disease types, physical and behavioral health needs, cognitive impairments, and acuity levels;- Physical environment, equipment, services, and cultural/religious factors that may affect care.- Facility resources including staffing, equipment, therapy, pharmacy, behavioral health services, and all contracted services.- Responsibility for completion…

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 interviews, and review of facility policies, it was determined that the facility failed to ensure that residents are treated with dignity and respect for one of 35 residents reviewed. (Resident R183)Findings include: Review of Resident R 183's quarterly Minimum Data Set (MDS-a federally mandated assessment tool for all residents) dated September 4, 2025, revealed that Resident R183 was admitted to the facility on [DATE], with diagnoses of hypertension (high blood pressure), asthma (condition that causes the airways to swell, narrow and fill with mucus), and bipolar disorder (mental condition that causes extreme mood swings). The residents' cognitive status, as measured by the Brief Interview for Mental Status (BIMS), yielded a score of 10, indicating moderate cognitive impairment. Observation on September 16, 2025, at 08:30 a.m. on the second-floor nursing unit revealed Licensed Nurse, Employee E12 administering medications to Resident R183. Licensed nurse, Employee E12…

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, staff interview, and review of facility policies, it was determined that the facility failed to ensure that one of 33 residents reviewed was assessed to self-administered medications. (Resident R77)Findings Include: Review of the facility's policy titled Medication Self-Administration revealed that residents are not permitted to retain or self-administer medications in their rooms unless the primary physician writes an order authorizing self-administration and the interdisciplinary team determines the resident is capable of doing so safely. An evaluation of the resident's ability to self-administer must be conducted and documented. The physician's order must be signed and dated prior to self-administration. Self-administration must be reflected in the resident's care plan and reviewed at least quarterly or upon any clinical change in the resident's status.Review of Resident R 77's Minimum Data Set (MDS- a federal mandated assessment tool for all residents) dated…

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 interview with residents and staff, it was determined that the facility failed to ensure to maintain privacy for resident's clinical records during medication administration and incontinence care for two of thirty-one residents observed (Resident R168 and R207). Findings include:Review of undated facility policy title HIPAA Security Measures revealed that under section Policy: It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality integrity and availability of resident's identifiable information and or records that are in electronic format. Under section Policy Explanation and Compliance Guidance #1. Facility leadership will ensure the implementation of policies and procedures to prevent detect contain and correct any security violations. #3. Only appropriate employees will have access to electronic protected health information. #8. Physical safeguards will be implemented that limit physical access to its electronic information systems and the facility of facilities…

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 staff interview, it was determined that the facility failed to maintain a safe, clean, and comfortable environment in a manner that promotes a homelike atmosphere for residents for one of 33 residents reviewed (Resident R1 and Resident R62) and on one of four nursing floors. (Third floor)Findings Include:Review of facility policy titled, Resident Rights undated states that the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Further review of the policy states that residents have the right to a 8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Observations conducted during a tour of the Third Floor on September 15, 2025 at 9:40 a.m. revealed the following: At 10:01 a.m. the Third-floor high side had foul odors 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 observations of care and services, reviews of facility policies and procedures, interview with residents and staff, reviews of facility documentation and clinical records, it was determined that the facility failed to ensure that allegations of verbal abuse, mental abuse and physical abuse were reported promptly and thoroughly investigated for three of thirty-one residents reviewed. (Resident R2, Resident R148, Resident R211 and Resident R45) Findings include:A review of the undated policy titled abuse, neglect and exploitation revealed that it was the responsibility of the facility to provide protection for each resident to prohibit and prevent abuse, neglect, exploitation and misappropriation of property.The policy indicated that alleged allegations of abuse (psychological, neglect for the provision of safe care for residents, verbal abuse, misappropriation of property and sudden changes in behaviors such as fear of a person) would be thoroughly investigated immediately. All alleged violations 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, review of facility documents, job descriptions and interview with staff it was determined that the facility failed to ensure that a qualified staff performs a wound assessment for one of nine residents reviewed (Resident R13)Review facility job description for licensed nursing staff revealed Job summary qualifications responsibilities duties and tasks of a charged nurse. Further review of the facility's job description for a charged nurse revealed that there was no specific job description for a registered nurse and there was no specific job description for a licensed practical nurse.Review of Resident R13's clinical record revealed that Resident R13 was admitted to the facility on [DATE], with diagnoses of but not limited to Hypertension, Rheumatoid Arthritis, HypothyroidismReview of Resident R13's skin assessment dated [DATE], revealed that resident was at risk for skin breakdown with a score of 17.Further section G (Additional observation) of Resident R13's skin assessment…

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 physical environment of the building on the first floor, reviews of the pest control operators reports and interviews with staff, it was determined that the facility was not maintaining an effective pest control program. Findings include:Observations of the physical environment of the facility revealed that the food and nutrition department was located on the first floor (ground floor) of the building. Further observations revealed that the trash and refuse area for the entire building was located through the double doorway in the back hallway that was adjacent to the main kitchen and dry food storage area. Observations of the double doors leading directly outside the building and into a driveway where the trash and garbage disposal system (dumpster unit) was held, revealed that these doors did not seal upon closing. A two-inch void was visible between the doors. The gap provided easy access for common household pests and rodents (mice, flies, roaches) to enter the building on the first floor. A review of the pest control operator's reports for September…

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

Based on observation, staff interview, and clinical record review, it was determined that the facility failed to ensure that a medication label was accurate for one of (Resident R3). Findings include: Review of Resident R3's April 2026 physican orders revealed an order dated March 19, 2025, for Potassium Chloride Liquid 20 MEQ/15ML (10%), Give 20 mEq via PEG-Tube one time a day for Hypokalemia (low Potassium Levels) Observation conducted of the label on the medication for Potassium Chloride revealed Potassium Chloride Liquid 20 MEQ/7.5 ML. On April 28, 2025, at 10:31 a.m., interview with the Director of Nursing revealed that the Pharmacy wrongly labelled the dose of Potassium Chloride Liquid 20 MEQ/15ML (10%), for R3 as to administer 7.5 ML, instead of 15 ML. 28 Pa. Code 211.9(a)(1) Pharmacy services

Based on clinical record reviews, interviews with residents and staff, reviews of policies and procedures and food committee meeting minutes, it was determined that for eight of nine residents reviewed, the facility failed to ensure that suitable and nourishing snacks were provided for the residents who wanted to eat at non-traditional times, outside of the scheduled meal service schedule. (Residents R111, R23, R476, R95, R145, R133, R162 and R167). Findings include: A review of the facility policy titled the serving of between meal and bedtime snacks dated September, 2010 revealed that it was the facility's responsibility to provide each resident with adequate nutrition. The policy indicated that bedtime snacks were to be placed on the overbed table or serving area for each resident. Nursing staff were responsible for positioning all residents so that the bedtime snack was easily reachable. Each resident was to be placed in upright position. All residents were to receive assistance with eating their bedtime snacks (foods and beverages) as necessary, by the nursing staff. A group…

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 with staff, and a review of facility procedures, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings include: Review of facility policy, Ware washing, revised February 2023 indicated that the dining services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware. An initial tour of the main kitchen was conducted on December 16, 2024, at 9:38 a.m. with the Food Service Director (FSD), Employee E11. Interview with Employee E11, revealed that the facility dish machine is operating as a low temperature machine, primarily relying on chemical sanitation. Observations at 8:45 a.m. revealed dietary staff, Employee E13 and Employee E14, were starting the dishwasher to clean dirty dishware. Employee 13 and Employee 14 completed two loads of dirty dishes and stored them to dry. Further observations revealed that a test load of dishes was not conducted and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility policy,and interviews with staff, it was determined that the facility failed to develop and implement a comprehensive care plan related to Resident R46's diagnosis of physical aggression, paranoia, insomnia and Resident R170 needing oxygen therapy for two of 33 resident records reviewed Findings include: Review of the facility policy titled, Comprehensive Care Plan, dated November 2019, states, It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Review of Resident R46's quarterly MDS (Minimum Data Set, an assessment tool used to evaluate the functional abilities and cognitive status of a resident) dated July 16, 2024, revealed the resident was alert and oriented capable 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 clinical records, interviews with staff, and facility policy, it was determined the facility failed to provide treatment and services in accordance with professional standards of practice related to a failure to conduct routine testing to verify therapeudic levels of a seizure medication. The facility failed to clarify the orders when a medication for epilepsy was decreased in error, and failed to inform the physician of a recommended psychotropic dose increase for one of 33 resident records reviewed. (Resident R46 ) Findings included: Review of the facility's policy, Medication and Treatment Orders revised October 2016 states, Orders for medications and treatments will be consistent with principles of safe and effective order writing . Review of Resident R46's quarterly MDS (Minimum Data Set, an assessment tool used to evaluate the functional abilities and cognitive status of a resident) dated July 16, 2024, revealed the resident was alert and oriented capable of making independent decisions, diagnosed with epilepsy, (a chronic brain disorder that causes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that residents with limited range of motion received treatment and services to maintain or improve range of motion/mobility for two of 36 residents reviewed for limited range of motion (Resident R7 and Resident R37). Findings include: Observation conducted during the tour of the second-floor unit on December 16, 2024, at 9:34 am revealed that Resident R7 was in bed with his left arm in a fixed position on his chest. Review of Resident R7's clinical record revealed that Resident R7 was admitted to the facility on [DATE], with diagnoses of but not limited to Paraplegia, Multiple Sclerosis, Acquired Absence of Right and Left Leg, Muscle Weakness, Contractures of Muscles Multiple Sites. Review of Resident R7's quarterly MDS (Minimum Data Set, a federally required assessment completed at a specific interval) dated October 7, 2024 section GG0115…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of clinical records, observation, facility documentation and interviews with staff, it was determined that the facility failed to ensure that the residents' environment was free of accident hazards, and failed to ensure that hazardous material were not accessible to a resident in one nursing unit of one of three nursing units. (Third floor) Findings include: Review of Resident R575's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis' including opioid dependence with withdraw, other psychoactive substance dependence, homicidal ideations, nicotine dependence with withdrawal, homelessness, and suicide attempt. Review of MDS (minimum data set, assessment of resident care needs) for Resident R575 dated December 11, 2024, revealed that the Resident R 575 had a BIMS (brief interview for mental status) score of 15 which indicated the cognitive status of the resident was intact. Review of hospital record for Resident R 575 dated November 7, 2024,…

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

Based on clinical record review, interviews with staff and reviews of policies and procedures, it was determined the facility failed to ensure a medication were administered with adequate indications for use and monitoring for two of 33 resident clinical records reviewed (Resident R46 and R83). Findings include: A review of the policy titled antipsychotic medication use dated December 2016 revealed that the antipsychotic medications would be prescribed by the physican at the lowest possible dosage for the shorest period of time. The policy also indicated that psychotropic medications were to be evaluated by the physician for gradual dose reduction routinely. The policy said that residents would only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated. The policy indicated that the need to continue as needed orders for psychotropic medications beyond 14 days required that the physician document the rationale for the extended order. Review of Resident R46's quarterly MDS (Minimum Data Set, an assessment tool used to evaluate the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records review and staff interview, it was determined that the facility failed to obtain a laboratory study as ordered by the physician for one of 33 clinical records reviewed. (Resident R158) Findings include: Clinical record review for Resident R158 revealed a diagnosis of obesity (overweight with excess body fat). Resident R158 was 68 inches in height and weighed 231 pounds indicating a weight of 25% above the ideal body weight of 154 +/- 10%. Clinical record review for Resident R158 revealed a quarterly MDS dated [DATE] that indicated that this resident was at high risk for pressure sore development and had moisture associated skin damage. Clinical record review for November 13 and 15, 2024 revealed that the physician had ordered laboratory studies of the blood to review the metabolism of albumin (a blood test to determine nutritional deficiencies and measure liver and kidney function) and thyroid (a gland that controls metabolism which effects how your body uses energy, regulates body…

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, staff interviews, and review of clinical records, it was determined this facility failed to establish and maintain enhanced barrier precautions for one resident of eight resident reviewed (Resident R15). Findings include: Review of the CDC Center for Disease Control and Prevention title enhanced barrier precaution and skilled nursing facilities dated November of 2022, revealed that enhanced barrier precautions (EBPS) in addition to standard precautions, are utilized to prevent the spread of multi drug resistant organisms to residents. Enhanced barrier precautions employees targeted gown and gloves use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gowns are applied prior to performing the high contact resident care activity as opposed to before entering the room. All protective equipment is changed before caring for another resident. Example of high contact resident care activities requiring the use of gown and gloves for enhanced…

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

Based on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility regarding the elopement of one of three residents reviewed.(Resident R1) Findings include: Review of the job description for the Nursing Home Administrator (NHA) stated, The Administator is responsible for planning and is accountable for all activities and departments of the center subject to rules and regulations promulgated by government agencies to ensure proper healthcare services to residents. The Administrator administers, directs and coordinates all activities of the center to assure that the highest degree of quality of care is consistently provided to the residents of the facility. Review of the job description for the Director of Nursing (DON) stated, The Director of Nursing is responsible for administration of nursing service in the nursing center. He/she directs, plan and coordinates service activities of professional nursing and auxiliary nursing personnel in…

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

Based on staff interviews, review of clinical records and review of facility policy, it was determined that the facility failed to ensure professional standards of practice related to medication administration for one out 3 residents reviewed (Resident R1). Findings include: Review of the policy Medication Administration, dated 05/16 indicated that for residents who are not in their rooms or otherwise unavailable to receive medication on the pass, the MAR is flagged. After completion of the medication pass, the nurse returns to the missed resident to administer the medication. The policy also indicated that the resident is always observed after administration to ensure that the does was completely ingested. Continued review of the policy indicated that topical medications used in treatments are listed on the treatment administration record (TAR). Review of the April 2024 physician orders for Resident R1 included the diagnoses of St. Elevation myocardial infarction (a type of heart attack); heart failure (when the heart muscle doesn't pump blood as well as it should) encephalopathy…

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

Based on staff interviews, review of clinical record and review of facility policy, it was determined that the facility failed maintain complete and accurate clinical records regarding an elopement event for one out of three residents reviewed (Resident R1). Findings include: Review of the facility policy, Documentation in Medical Record dated April 23, 2024 indicated that resident medical records shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation. Review of the April 2024 physician orders for Resident R1 included the diagnoses of St- Elevation myocardial infarction (a type of heart attack that affects the lower chambers of the heart); heart failure (when the heart muscle doesn't pump blood as well as it should) encephalopathy (a general term describing a disease that affects the function or structure of an individual's brain), and schizophrenia (a mental disorder characterized by false beliefs that conflict with reality,…

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 staff and resident interviews, it was determined that the facility failed to ensure that a resident was informed of and allowed to participate in decisions regarding the resident's care and treatment for one of five residents reviewed (Resident R1). Findings Include: Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 29, 2924, revealed the resident was cognitively intact and had diagnoses of anxiety and depression. Interview on April 18, 2024, at 12:27 p.m. with Resident R1 revealed the resident recently missed doses of Trazodone, a medication used to help the resident sleep. Resident R1 reported that nursing staff told him the medication was discontinued by the physician but was unable to explain why. Further interview with Resident R1 revealed poor sleep during the days Trazodone was not provided. Continued interview on April 18, 2024, at 12:27 p.m. with Resident R1 revealed the physician did not inform the resident of the…

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

Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: The Policy: Food Storage: Cold Foods, updated February 2023, states, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. An initial tour of the Food Service Department was conducted on March 25, 2024, at 10:15 a.m. with Employee E3, Food Service Director, FSD, which revealed the following: Observation in the corridor between the receiving door to the outside and the kitchen was very dusty and dirty with visible dirt and debris on the floor. Observation in the dry storage room revealed a pan rack with a reddish substance splashed over the rack, and the floor littered with paper, straws, packets and dust, and there was less than the required 18 between boxes (Dart Styrofoam cups, Steamtable Pan Lids, Latex Gloves) on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for four of 36 residents reviewed (Resident R131, R37, R42 and R123). Findings Include: Review of the undated Consultant Pharmacist Services Provider Requirements Policy revealed, Medication Regimen Reviews (MRR) for each skilled nursing resident at least monthly, communicate to responsible prescriber, the facility's medical director and the director of nursing potential or actual problems detected, and other findings related to medication therapy orders at least monthly, review and follow-up to previous month's pharmacy recommendations with the nursing care center staff. Review of Resident R131's clinical record revealed that resident was admitted on [DATE], with diagnoses including multiple sclerosis (a chronic autoimmune disease that affects the central nervous system with symptoms including muscle weakness, spasticity and paralysis),…

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 interviews with staff, it was determined that the failed to ensure complete and accurate documentation related to tuberculosis testing for three of three residents reviewed (Resident R480, R479, R134). Findings include: Clinical record review for Resident R480 revealed an admitting diagnosis of chronic kidney disease on March 8, 2024. Continued review of clinical record revealed an order for TB skin test per protocol. Screening #1 to be administered within the first 24 hours of admission on March 8, 2024. Review of Resident R480's March 2024 Medication Administration Record (MAR) revealed code 1 indicated for this administration. When looking at the key it was revealed that code 1 is absent from home without medication. Continued review of clinical record revealed an order for TB skin test per protocol. Step #2 per protocol on March 15, 2024. MAR revealed code 1 indicated for this administration. When looking at the key it was revealed that code 1 is absent from home without medication. Further review of MAR revealed an order for TB skin test per…

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 four dialysis residents reviewed (Resident R148). Findings include: Review of Resident R148's clinical record revealed that the resident was admitted to the facility on [DATE], and that Resident R148 had diagnoses 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 R148's physician order, dated February 15, 2024, revealed Revealed that Resident R148 receive dialysis treatment at an outpatient dialysis facility on Mondays, Wednesdays, and Fridays. Review of Resident R148's Hemodialysis Communication Record revealed that on, March 1, 2024 and March 4, 2024 it was lacking information on Pre-Weight, Post- Weight, Pre-Blood Pressure, Post-Blood…

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

Based on observations, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to maintain sufficient dietary personnel to complete essential job functions, related to meals being served late. Findings include: Observations in the main kitchen on March 25, 2024, at 10:50 a.m. revealed the stacks of dirty dishes and tray delivery carts full of trays with dirty dishware that still had to be unloaded, scrapped, stacked, racked, rinsed and run through the dish machine. After the dishes were cleaned, they needed to be stacked in the plate warmers, trays after air drying had to be stacked and preset for the lunch meal, the silverware had to be rinsed, washed, sorted, air dried and set up on the lunch trays. Interview with on March 25, 2024, at 1:08 p.m. with Licensed nurse, Employee E10, confirmed that the lunch trays were late, that they are usually delivered much earlier. Interview with on March 25, 2024, at 1:10 p.m. with Resident R82 revealed that she had not received her tray yet, that it very late for lunch. Interview with…

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

Based on 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 linen washing and processing, in one of one laundry room in the facility. (laundry room) Findings include: Observation at the laundry room of the facility, on March 28, 2024, at 12:14 p.m., revealed that two Laundry Aides, Employees E15 and E16, were processing and folding clean linens for the use of residents by holding the linens letting it to touch the Laundry Aides' personal clothing. It was also observed that while folding the washed and dried linens for the use of residents, the clean linens were in close contact with Employee E15's beard. At the time of the finding interviewed with Employees E15 and E16, confirmed that the linen should have been folded without letting it touch the employee's clothing to prevent contamination and to maintain infection control. 28 Pa Code 211.12 (d)(1)(5) Nursing services 28 Pa Code 201.14(a) Responsibility of licensee

Based on the review of employee job description, clinical records and interviews with staff, it was determined that the facility failed to complete a skin assessment according to professional standards of nursing practice. (Employee E4) Findings Include: Review of job description for Unit Manager, revealed that Unit Manager will oversee the medical and personal care of residents and supervise the nurses and other caregivers who interact with the residents on a daily basis in accordance with state and federal regulations to promote high quality of care and service. Responsibilities: Ensures complete and prompt reporting of incidents with follow-up as necessary to Administrator and Director of Nursing. Oversee resident care to promote the highest level of physical, mental and psychosocial functioning possible for assigned unit. Ensures that significant changes in resident condition are communicated to the physician, family or responsible party. Makes daily rounds on unit to ensure resident care needs and environmental standards are met, this includes monitoring of dining rooms meal…

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, review of facility policy and interviews with staff, it was determined the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice for one of four clinical records reviewed (Resident R1). Findings include: Review of CDC (Centers for Disease Control and Prevention), Guidelines for Preventing Health-Care--Associated Pneumonia, 2003, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee recommendations revealed that, Prevention of Person-to-Person Transmission of Bacteria 1. Standard Precautions a. Hand hygiene: Decontaminate hands by washing them with either antimicrobial soap and water or with nonantimicrobial soap and water (if hands are visibly dirty or contaminated with proteinaceous material or are soiled with blood or body fluids) or by using an alcohol-based waterless antiseptic agent (e.g., hand rub) if hands are not visibly soiled after contact with mucous membranes, respiratory secretions, or objects…

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

Based on the review of facility policy, interviews with staff, it was determined that the facility failed to ensure that the nursing staff possessed appropriate competencies for tracheostomy care for one of one employee record reviewed. (Employee E5). Findings Include: Review of CDC (Centers for Disease Control and Prevention), Guidelines for Preventing Health-Care--Associated Pneumonia, 2003, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee recommendations revealed that, Prevention of Person-to-Person Transmission of Bacteria 1. Standard Precautions a. Hand hygiene: Decontaminate hands by washing them with either antimicrobial soap and water or with nonantimicrobial soap and water (if hands are visibly dirty or contaminated with proteinaceous material or are soiled with blood or body fluids) or by using an alcohol-based waterless antiseptic agent (e.g., hand rub) if hands are not visibly soiled after contact with mucous membranes, respiratory secretions, or objects contaminated with respiratory secretions, whether or not gloves are worn.…

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

Based on a review of clinical records, facility documentation and interview with staff, it was determined that the Nursing Home Administrator and the Director of Nursing did not ensure to effectively manage the facility related to prevention of pressure ulcers and pressure injuries (PU/PI) for one of one residents reviewed (Resident R1) Findings include: Review of the job description for the Nursing Home Administrator (NHA) revealed The administrator is responsible for planning and is accountable for all activities and departments of the center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs and coordinates all activities of the center to assure that the highest degree of quality care is consistently provided to the resident of the facility. Review of job description for the Director of Nursing (DON) revealed The Director of Nursing is responsible for administration of nursing service in the nursing center. He/she directs plan and coordinates service activities 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, and staff interviews, it was determined that the facility failed to implement proper use of personal protective equipment (PPE) when practicing enhanced barrier precautions during tracheostomy care and failed to follow enhanced barrier precautions as ordered by the physician. One of four resident records reviewed. (Resident R1) Findings Include: Review of an undated facility policy Enhanced Barrier Precaution revealed that Enhanced barrier precautions referred to the use of gown and gloves for use during high-contact resident care activities for resident known to be colonized or infected with a MDRO (Multidrug-resistant bacteria are bacteria that are resistant to three or more classes of antimicrobial drugs.)as well as those at increased risk of MDRO acquisition. An order for enhanced barrier precautions will be obtained for residents with any of the following 1. Wounds and/or indwelling medical devices ( eg. Tracheostomy/ventilator tubes). Implementation of enhanced barrier precautions- a. Make gowns and gloves available immediately…

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 interview with staff, it was determined that the facility did not ensure that appropriate notices were provided related to transfer to the hospital/discharge for four of 40 records reviewed (Residents R52, R70, R71, R326). Findings include: Review of Resident R52's clinical record revealed that the resident was sent to the hospital on July 17, 2023, due to blockage of his suprapubic catheter (a tube surgically inserted through the skin over the pubic bone in order to drain urine from the bladder). Review of Resident R70's clinical record revealed that the resident was sent to the hospital on August 8, 2023, due to exacerbation of CHF (congestive heart failure, a condition in which the heart does not pump efficiently, which causes fluid to back up in the system, causing weight gain, edema and difficulty breathing). Review of Resident R71's clinical record revealed that the resident was sent to the hospital on August 27, 2023, due to elevated temperature and a swollen, discolored right hand. Review of Resident 32's clinical record revealed that the…

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