Ivy Hill Post Acute Nursing & Rehabilitation LLC

Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services.Findings include: An interview on March 9, 2026, at 9:20 a.m. with Employee E3, Food Service Director (FSD), revealed that her responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Further interview with the FSD confirmed that she was not a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; or had an associate's or higher degree in food service management or hospitality from an accredited institution; and that she had not received frequently scheduled consultations from a qualified dietitian. A review of Employee E12's credentials revealed that Employee E12 did not meet the statutory qualifications of a director of food and nutrition services. During an interview on March 10, 2026, at 12:15 p.m. with Employee E1, the Nursing Home Administrator,…

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 assessment and staff interview, it was determined that the facility failed to ensure the direct care staff and input from residents, resident representatives, and/or family members was included when conducting the facility assessment. Findings include: Review of the facility's facility assessment, dated July 28, 2025, revealed there was no indication that the facility involved direct care staff, input from residents, resident representatives, and/or family members. Interview with Employee E2, Director of Nursing, on March 12, 2026, at 10:20 a.m., confirmed there was no direct care staff, resident representatives, and/ or family members included in the facility assessment. 28 Pa. Code 201.18(b)(3) Management28 Pa. Code 211.12(c)(d)(1) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident and staff interviews, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, comfortable, and homelike environment for three of three nursing units observed (first floor, second floor, third floor). Findings include: On March 24, 2025, at 12:57 p.m., Unit Manager Employee E19 confirmed that Resident R37 in room [ROOM NUMBER]-2 did not have access to a locked drawer at his bedside to store his personal belongings. Resident R37 had filed a grievance on January 3, 2025, regarding the missing $80, which was not reimbursed, and had been promised a locked drawer to secure his personal items. Observation on March 25, 2025 at 11:44 a.m. in room [ROOM NUMBER] revealed Resident R15 lying in bed in a fetal position. Interview with Resident R15 on March 25, 2025 at 11:45 a.m. revealed room [ROOM NUMBER] did not have a working heating unit. Resident R16 further stated the middle part of her bed was broken and she is unable 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 observations of care and services, interviews with residents and staff and reviews of policies and procedures, it was determined that the facility failed to ensure that three of 38 residents were protected from inappropriate sexual behaviors from one resident. (Residents R63, R44, R82) Findings include: A review of the undated facility policy titled resident rights, abuse, neglect, mistreatment or misappropriation of resident property revealed that it was the responsibility of the facility to prevent abuse, neglect, mistreatment or misappropriation of resident property. All staff were responsible for reporting and investigating abuse including resident to resident abuse. All employees would be screened for convictions of abuse. Residents would be screened by the social worker for personal or family history of abuse. All employees, including management staff and volunteers would receive training upon orientation and annually about recognizing, reporting and prevention of abuse. The training was 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 reviews of personnel files and the Department of State documents, staff interviews and reviews of policies and procedures, it was determined that the facility failed to perform criminal history background checks for two of two volunteer files (Employees E10, and E11) reviewed and the facility failed to ensure residents were protected from abuse by implementing the established abuse policy (Residents R63 and R44). Findings include: A review of the undated facility policy titled resident rights, abuse, neglect, mistreatment or misappropriation of resident property revealed that it was the responsibility of the facility to prevent abuse, neglect, mistreatment or misappropriation of resident property. The policy indicated that all staff were responsible for reporting and investigating abuse including resident to resident abuse. The policy indicated that all employees would be screened for convictions of abuse. The nurse aide registry, licensing authorities and references would be referenced for each employee prior to hire. Residents would be screened by the social worker for…

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

Based on review of clinical records and interview with staff, it was revealed that the facility did not ensure revisions were made to the PASRR (Pre-admission Screening and Resident Review) application to include mental health diagnoses for 3 out of 3 residents reviewed. (Resident R108, R10, R90). Findings include: Review of Resident R108's PASRR completed on January 31, 2024, indicated that Resident R108 had no mental health diagnosis. Review of R108's clinical record revealed on May 2, 2024, obtained a mental disorder and on April 4, 2024, obtained an anxiety disorder. A review of Resident R10's PASRR completed on February 24, 2023, indicated that Resident R10 had a mental health condition of Schizophrenia (serious mental health condition that affects how people think, feel, and behave) , altered mental status. A review of the resident diagnosis revealed that Resident R10 also had mood disorder due to known physiological condition as of July 24, 2023. Clinical record review revealed Resident R90 had a mental diagnosis of Bipolar Disorder (mental health condition 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.

Based on personnel record review, and staff interview, it was determined that the facility failed to provide abuse, neglect and exploitation training for two of two volunteer staff reviewed (Employee E10, and E11). Findings: A review of the Facility Policy titled Residents/Patient Right-Abuse, Neglect, Mistreatment or Misappropriation of Resident/Patient's Property undated, revelated All employees, including management staff and volunteers, will receive training upon orientation and annually. In-services regarding abuse, neglect, mistreatment or misappropriation of resident's/patient's property. Training will include how staff should report their knowledge of allegations without fear of reprisal; How to recognize signs of burnout, frustration and stress that may lead to abuse On March 26, 2025, at 2:04 p.m. an interview with Volunteer Pastor, Employee 10 revealed that he and his wife, Employee E11 had been coming to the facility for 22 years to conduct religious activities. On March 28, 2025, at 1:15 p.m. an interview with the Human Services Director, Employee E12 revealed that she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews with residents and staff and reviews of policies and procedures, it was determined that for one of two residents reviewed that the interdiciplinary care planning team failed to assess each resident for self adminitration of medications and determine if the practice was clinically appropriate and safe in accordance with their residents rights. (Resident R94) Findings include: A review of the undated facility policy titled self-medication administration revealed that it was each resident's right to manage their medications independently within the nursing home. The policy indicated that the facility was responsible for assessing each resident to deem if the resident was capable of safely managing their own medications. Clinical record review for Resident R94 revealed a quarterly comprehensive assessment dated [DATE] that indicated this resident was cognitively intact, had no swallowing problems with foods or fluids. The assessment also indicated that the resident had…

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

Based on 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 grivance was promptly documented and resolved for one of 26 resident records reviewed. (Resident R95) Findings Include: The facility will fully investigate and respond to all concerns or complaints regarding patient/resident care and/or treatment. The patient/resident/ resident representative has the right to file a grievance orally, in writing, or anonymously. All grievances will be responded to within 48-72 hours, and in writing if requested. On March 24, 2025, at 12:55 p.m., an interview was conducted with Resident R37, who reported that $80 had gone missing in January 2025. The facility investigated the concern but did not issue a refund, stating that the amount was not documented on the resident's inventory sheet. Resident R37 also mentioned that the facility had promised to provide a locked drawer for storing his personal belongings. At 12:57 p.m. on the same day, Unit Manager…

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, observations, and staff interviews, it was determined that the facility failed to identify the placement of beds against the wall as a restraint, the use of a seatbelt on a wheelchair as a restraint, and did not assess the functional status of an individual resident to determine the appropriateness of using a restraint for two of the 26 residents reviewed (Resident R108 and Resident R26) Findings Include: Review of Resident R108's clinical record revealed that the resident was admitted to the facility February 1, 2024, with a diagnosis of difficulty in walking, and encephalopathy (disease that affects the brain's structure or function). On March 24, 2025, at 12:52 p.m., Resident R108 was observed sitting in a wheelchair in the dining room with a seatbelt fastened across his waist. The seatbelt was locked, preventing the resident from being able to release it. This observation was confirmed by the unit manager, Employee 19, who reported that Resident R108 does not have an order for the use of a seatbelt restraint and expressed uncertainty as 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 facility policy, facility documentation, review of clinical records, and interview with staff; it was determined the facility failed to develop a comprehensive care plan and interventions to address Resident R30's recent overdose, Resident R36's lack of toiling program and Resident R69's past traumatic stress disorder (PTSD) abd self administration of medication (Resident R94) for 4 of 26 residents reviewed. (Resident R30, R36, R69, R94) Findings include: Review of facility policy titled Interdisciplinary Care Planning Protocol undated, revealed Nursing admission Assessment completed on day of admission but in no event later than 24 hours of admission. Nursing Initiates interim Care Plan-the interim care plan must address all immediate care needs. Review of Resident R30's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis of other low back pain, opioid dependency, and anxiety disorder. Review of Resident R30's quarterly Minimum Data Set 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 resident and staff interview, review of facility policy and staff interview, it was determined that the facility failed to properly supervise residents during medication administration for one of 26 residents reviewed (Resident R57). Findings include: Review of Facilities' policy titled Administering medications reviewed January 18, 2025 revealed under section Policy Interpretations and Implementation stated only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. Never leave a medication unattended in a resident's room. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of Resident R57's clinical record revealed that the resident was admitted to the facility August 9, 2019 with a diagnosis of Traumatic Brain Injury, Hypokalemia (low potassium), and Hypertension (high blood pressure), Depression and Anxiety. Review of Resident…

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

Based on observation, clinical record review, interview with staff and review of policies, it was determined that the facility failed to ensure that a resident was provided with devices to optimize posture during dining and failed to collect additional nutritional biochemical data related to the resident's nutritional status for one of five residents reviewed. (Resident R63) Findings include: A review of the undated policy titled nutrition evaluation indicated that it was the facility's responsibility to ensure that each resident received proper nutrition and dietary support to promote their health and well being. The policy also indicated that each resident would undergo a nutritoinal assessment by a registered dietitian. The dietitian was responsible for assessing the resident's medical history, dietary preferences, allergies and and special dietary needs. The dietitian would also be responsible for assessing biochemical data collected related to a resident's nutritional status. The facility would collaborate the healthcare professionals (physician, nursing, dietitian occupational…

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, review of facility policy and staff interview, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for one of one resident reviewed (Resident R23). Findings include: Review of facility policy titled Oxygen Therapy, no date, revealed Oxygen (02) is administered appropriately to residents to improve oxygenation and provide comfort to residents experiencing respiratory difficulties. Oxygen is administered by licensed staff with a physicians order. In an emergency oxygen can be administered and order should be received as soon as possible. Clinical record review revealed Resident R23 was re-admitted to the facility on [DATE] with a diagnosis of sepsis (serious condition in which the body has a severe response to an infection), chronic obstructive pulmonary disease (lung condition caused by damage to the airways that limit airflow), and hypertension (high blood pressure). Observation on March 24, 2025 at 11:28 a.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of clinical records, facility documentation, and staff interviews, it was determined the facility failed to ensure that pain level assessments were accurate for one of the 2 residents reviewed (Resident R30) . Findings include: Review of Resident R30's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis of other low back pain and opioid dependency. Review of Resident R30 physician's orders dated, December 13, 2024, revealed an order for pain assessment every shift for pain assessment. Continued review of December 2024 physician order revealed and order dated December 15, 2024, through March 8, 2025, for Oxycodone tablet 10 milligrams (mg) give 1 tablet every 6 hours for pain. Review of Resident R30's March 2025 physician orders confirmed and order date March 8, 2025 through March 19, 2025, for Oxycodone oral tablet 10 mg give 1 tablet by mouth every 12 hours for pain. Continued review of physican orders revealed and ordered dated March 19, 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.

Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma informed care in accordance with professional standards of practice, accounting for the resident's past experience and preferences in order to eliminate and /or mitigate triggers that may cause re-traumatization of the resident for one of four residents reviewed. (Resident R 69) Findings include: Review of facility policy titled Trama Informed Care,revealed the facility ensures that residents who are trauma survivors receive culturally competent, trauma informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Upon admission the facility will assess each resident to ensure they receive appropriate treatment and services. A questionnaire will be utilized for each resident by the social services department in order to identify any trauma and/or post-traumatic stress disorder 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 a review of clinical record review, and interviews with staff, it was determined that the facility failed to ensure that medication regimens were followed by the facility in a timely manner for two of the five residents reviewed related to medication regimen reviews (Residents R30 and R61). Findings include: Review of Resident R30's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis with atherosclerotic heart diseases of native coronary artery without angina pectoris, and cerebral infarction (stroke). Continued review revealed that the resident received Atorvastatin Calcium Oral Table 80 milligrams give 1 tablet by mouth prescribed by the physician on December 13, 2024. A Pharmaceutical review of the Medication Regimen was conducted on December 23, 2024, and February 26, 2025 revealed a recommendation for Lipids suggested with 80 mg (milligrams) Atorvastatin. Review of Resident R30's clinical record revealed no documented evidience that a laboratory study…

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, and staff interviews, it was determined that the facility failed to ensure that as needed anti-anxiety medication was limited to 14 days unless a documented rationale was provided for one of eight residents reviewed for medication administration regimen. (Resident R69) Findings include: Review of physician orders for Resident R 69 dated March 25, 2025, revealed that there an order for Lorazepam (Ativan-this medication is used to treat anxiety) 1 mg, to give every twelve hours PRN (as needed) for agitation, end date is indefinite. Review of clinical record for Resident R 9 revealed no evidence that the attending prescribing practitioner documented the rationale for use as needed anti-anxiety medication in the resident's clinical record and indicated the duration for the prn order. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services

Based on review of the clinical records, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that a resident was free of significant medication error for one of four residents reviewed for medication administration relating to prescribed route of medication administration. (Resident R 116) Findings include: Review of facility policy titled Administering medications revised January 18, 2025, revealed that medications shall be administered in a safe and timely manner and in accordance with the physician order. The individual administering the medication must check the label to verify the right resident, for right medication, right dosage, right time, and rate route of administration before giving the medication. Review of Resident R116's quarterly Minimum Data Set (MDS- a federal mandated assessment tool for all residents) dated December 27, 2024 revealed that Resident R116 was admitted into the facility July 12, 2024 with diagnoses including renal failure (kidney failure) and traumatic brain injury. Resident R116 is on a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility documentation, and interviews with staff, it was determined that the facility failed to review and revise comprehensive person-centered plan of care in a timely manner, for one of 28 resident records reviewed (Residents R384). Findings include: Review of Resident R384's clinical records revealed an admission date of December 22, 2023. Review of Resident R384's clinical record revealed medical diagnosis of Meniere's Disease, (a rare inner ear condition that affects both balance and hearing), Malignant Neoplasm of Endometrium, (a type of cancer that begins as a growth of cells in the uterus, Hypertension, (high blood pressure), Muscle Weakness, Atrial Fibrillation,( an irregular and often rapid heart rate), Chronic Obstructive Pulmonary Disease, (obstructed airflow from the lungs), Myocardial Infraction, (heart attack), Protein Calorie Malnutrition, Osteoarthritis, (tissue and parts of joints gradually deteriorate), Nontraumatic Intracerebral Hemorrhage 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 observations of care and services and interviews with staff, it was determined that the facility failed to assess communication needs and ensure that appropriate treatment and services were provided to maintain the ability to speak and understand the preferred language for one of two residents reviewed. (Resident R10) Findings include: Observations of Resident R10 at 11:15 a.m., on June 10, 2024 revealed that this resident was in need of assistance with bathing, dressing and grooming. Resident R10 was unable to articulate his needs for assistance with activities of daily living. Interview with the licensed nursing staff, Employee E6, at 12:00 noon on June 10, 2024 revealed that Resident R10 was speaking his native language of Cambodian that the nurse could not understand. Clinical record review revealed a care plan for Resident R10 that indicated this resident has a language barrier and communication problem. There were no care plan measures to provide an interpreter for assessment purposes of cognitive ability and quality of life enrichment for Resident R10. There was no…

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

Based on observation, reveiw of physician's orders and interview with staff, it was determined that the facility to ensure that physician's order related to tube feeding was followed for one of twenty-eight residents reveiwed (Resident R14). Findings include: Review of Resident R14's clinical record revealed a physician's order dated June 9, 2024, for every 4 hours Bolus Feeding: Jevity 1.5 via PEG (percutaneus Gastroscopic Gastrostomy tube- a tube conneced to the stomach used to introduce liquid food into the stomach) , 237 ml bolus 6x/day, total volume 1422 ml per 24 hours. Further, a physican's order dated June 9, 2024 for NPO (nothing by mouth) was also in place. Observation conducted during tour of the second floor unit on June 10, 2024 at 9:37 am revealed that licensed nurse Employee E13 was administering a cream-colored liquid into Resident R14's peg tube using a large syringe. Further observation revealed that there was one cup of cream-colored liquid left on the overhead table which the Employee E13 was observed throwing out in the resident's toilet. Interview with the…

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

Based on observations of care and services, clinical record review, interviews with staff and reviews of policies and procedures. it was determined that the facility failed to ensure proper treatment and assistive devices to maintain vision for one of two residents reviewed. (Resident R10) Findings include: Review of the undated facility policy titled vision services revealed that it was the responsibility of the staff at the facility to assist each resident with obtaining vision services. The policy also indicated that it was the responsibility of the staff to notify the vision services provider for the necessary vision care services for the residents. The policy indicated that broken or damaged glasses was considered an emergent problem and that the vision service provider would be notified immediately for timely repair services for the resident. Clinical record review revealed a comprehensive quarterly assessment (MDS-an assessment of care needs) dated April 21, 2024 for Resident R10. The assessment indicated that Resident R10 required the use of corrective lenses for adequate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff and resident interviews, it was determined that the facility failed to ensure that a resident who exhibited new onset of decrease in functional abilities receive appropriate treatment and services to improve and prevent further deterioration for one of 28 was observed (Resident R 14). Findings include Observation of Resident R14 conducted during tour of the second-floor unit on May 10, 2024, at 10:42 am revealed that Resident was on his bed. Further, observation revealed that resident was not able to open right hand fully. Further, Resident R14's fingers remain in a in a flexed position when hands were open. interview with Resident R14 conducted at the time of the observation revealed that he doesn't have a splint and that he was not receiving PT (physical Therapy or OT (Occupational therapy) services. Review of resident R14 clinical record revealed that Resident R14 was originally admitted to the facility on [DATE]. Further review of Resident R14's medical…

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 review it was determined that the facility failed to monitor labs for one resident on fluid restrictions (Resident R75). Findings include: Review of Resident R75's clinical records revealed the resident was admitted into the facility on January 23, 2024, from the hospital. Resident R75's medical diagnosis include Guillain-Barre Syndrome (rare disorder in which immune system attacks nerves causing weakness, tingling and paralysis, and Myoneural Disorder (a rare autoimmune disorder that affects communication between nerves and muscles), Ataxic Gait (uncoordinated walking), Bipolar Disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Disorder of Lung, Osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down, Spondylosis (age-related wear and tear of the spinal disks), Scoliosis (sideways curvature of the spine), Kyphosis (a forward rounding of the back), Anxiety, Ulcerative Colitis (inflamed digestive tract), Hallucinations, and Neuromuscular Dysfunction (disorder 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 interview with residents and staff, observations, and review of clinical records it was determined that facility failed to address and/or obtain necessary services for behavioral health care needs for one of 28 residents reviewed (Resident R82) Findings include: Review of Resident R82's clinical record revealed resident was admitted to facility with history of paranoid personality disorder, psychophysiological insomnia and major depressive disorder. Resident has been 302'd [involuntary admission to psychiatric unit] prior to admission for suicidal attempt. Interview with R82 on June 10th, 2024 at 12:30 PM, revealed that the resident has been seeking grief group support due to past trauma of loosing family members/friends. Resident tearful during interview and stated that she does not wish to self-harm, is not interested in pharmacological interventions, and has been asking for non-pharmacological support; specifically, grief support group, which has been helpful in the past because she wants to interact with peers who are able to relate to what she is feeling and is going…

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, observation, and staff interview it was determined that the facility failed to ensure that all drugs and biologicals are stored and labeled in accordance with professional standards for two of two medication rooms observed (second floor and third floor medication rooms). Findings include: Review of facility Policy on storage of medications revealed that under section Policy Statement, the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Under section Policy Interpretation and Implementation #2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. Observation of the second -floor medication room conducted on June 11, 2024, at 11:46 am with licensed nurse Employee E13 revealed that a treatment cart was inside the medication room. Observation of the treatment cart revealed an opened tube of Santyl Collagenase inside the treatment cart. Further, the opened tube of Santyl did not have a label with resident's name attached to it.…

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, clinical record reviews, interviews with staff and policy and procedure reviews, it was determined that the facility failed to provide routine dental services from an outside resource to meet the dental needs for one of three residents reviewed. (Resident R36) Findings include: Review of the undated facility policy titled dental services revealed that it was the responsibility of the staff to assist each resident with obtaining routine and emergency dental care. The policy indicated that the facility was responsible for identifying dental needs through assessment and that the resident would receive dental services from an outside provider. Observations of Resident R36 during the noon meal on July 10, 2024 revealed that this resident was refusing to eat his meal. Resident R36 said that the foods did not taste good. It was observed at 12: 30 p.m., on June 10, 2024 on the third floor nursing unit while Resident R36 was speaking, that this resident had obvious or likely…

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, it was determined that the facility failed to ensure that proper infection control practices were observed related to tube feeding and medication administration for one of one tube feeding observation and one of five residents observed (R14 and R79). Findings include Observation conducted during tour of the second-floor unit on June 10, 2024, at 9:37 am revealed that licensed nurse Employee E13 was providing Resident R14 with tube feeding via bolus (A way to send formula through the feeding tube using a catheter syringe. Bolus feedings give large doses of formulas several times a day), further observation revealed that Employee E13, licensed staff, was wearing gloves on her right hand but was not wearing gloves on her left hand. Further, Employee E13 was using both hands to handle the feeding equipment, (large syringe, cups) Further observation revealed that the over bed table where the tube feeding equipment and the two cups of cream-colored liquid were placed were dirty and did not have any clean covering. Observation during medication preparation by licensed…

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 operations within the food and nutrition department, reviews of policies and procedures, interviews with staff, and reviews of the the chemical manufacturers guidelines, it was determined that the facility failed to maintain all mechanical dietary equipment in safe operating condition. Findings include: A review of the facility policy titled dish machine dated June 21, 2023 revealed that the dietary staff were responsible for washing, rinsing and sanitizing all dishes, bowls, cups, mugs, utencils, pots and pans after each meal. According to the policy the dietary staff were to test the chlorine using a test strip to ensure 50 ppm was being dispensed into the machine during the final rinse phase of dish washing. Observations of the dish machine on June 10, 2024 revealed that the low temperature dish machine was not registering (using a chlorine test strip) any chemical sanitizer (hypochlorite) during the final rinse cycle for proper cleaning and sanitizing of the dishes, bowls, cups, mugs, utencils, pots and pans. The chemical was unavailable for use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide a resident fund quarterly statement for one of two residents reviewed for personal funds. (Resident R2). Findings include: Facility policy titled Personal Funds undated revealed A copy of the quarterly statement will be submitted to the resident or the resident's designated representative (if resident is unable to comprehend or has requested that the statement be send to the representative ) on a quarterly basis/and or the request of the resident or designated representative. Review of Resident R2's clinical record revealed that resident was admitted to the facility on [DATE]. Review of the Resident R2's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated August 3, 2023, indicated that the resident's BIMS (Brief Interview of Mental Status) is severely cognitively impaired. On April 10, 2023, Resident R2 obtained a Power of Attorney (POA) to represent…

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

Based on review of clinical records and resident fund accounts, and staff interview, it was determined that the facility failed to provide a final accounting of funds within 30 days of transfer for one of two residents (Resident CR1). Findings include: Resident CR1's clinical record indicated that the residnet was discharged on June 5, 2023, to another nursing home facility. The billing statement showed that facility received Resident CR1's pension payment on June 30, 2023, of the amount of $2,383.56 and Social Security for the amount of $1,398.00. Facility charged the resident for 4 days of stay for the month of June of total $1,978.00; which equaled the balance to be reimbursed to the resident of $1,758.56. Facility reported insurance denial claims which resulted in delaying the reimbursement. Facility issued a reimbursement check of $1,758.00 to Resident CL1 on October 27, 2023. Which resulted in 4 months delay. The amount and the address was incorrect on the check and facility re-issued a check of $1,758.56 on November 3, 2023. During an interview on November 1, 2023, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview with resident, resident's representative, and staff, it was determined that the facility did not ensure that proper referral was initiated to transfer resident to another facility for one of the two residents reviewed. (Resident R2) Findings include: Review of Resident R2's clinical record revealed that resident was admitted to the facility on [DATE]. Review of the Resident R2's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated August 3, 2023, indicated that the resident's BIMS (Brief Interview of Mental Status) is severely cognitively impaired. On April 10, 2023, Resident R2 obtained a Power of Attorney (POA) to represent support the resident of making decisions. A review of the clinical record conducted during the onsite visit revealed the first social service note which was documented on October 18, 2023, in regards to Resident R2 transfer progress revealed that Resident R2 reported I really don't want to be nowhere But…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide written notice, including reason for the change, prior to moving a resident to another room, for four of 32 residents reviewed (Residents R86, R36, R16 and R4). Findings include: Review of facility policy, Room Change/Roommate Assignment dated December 1, 2022, revealed, Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives) will be given advance notice of such change . and will include the reason(s) for such change. Interview on August 14, 2023, at 12:27 p.m. Resident R4 stated that her room had been changed recently, that she was not given a choice or proper notice of the room change and that she did not like her room. Review of Resident R4's census information revealed that on May 26, 2023, the resident was moved from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-2. Continued…

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, clinical record review and interview with staff and residents, it was determined that the facility did not maintain a safe, clean, comfortable, homelike environment for two of three nursing units (First floor and Second floor). Findings include: Observations conducted on the First floor nursing unit on August 14, 2023, at 9:55 a.m. revealed a strong odor of cigarette smoke in the hall way near the entrance to the resident lounge, through which residents access the smoking area outside. Licensed nurse, Employee E14, stated [it]smells like smoke in this hall all the time, I try to keep the door closed. The door was noted to be near to the door of Resident R48, who had a tracheostomy and noted respiratory care needs. Observations conducted on the Second floor nursing unit on August 14, 2023, at 10:55 a.m. revealed a wet floor near the bed of Resident R3, which appeared to be coming from under the heating/air conditioning unit in the room. A fitted bed sheet and a blanket were under the unit. Resident R3 stated it's been like that for a while. A second wet area was…

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