Liberty Center For Rehabilitation And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility assessment and staff interviews, it was determined that the facility did not ensure active involvement of direct care staff and input from residents, resident representatives, and family members in the development and revision of the facility assessment. Additionally, the facility failed to identify within the facility assessment an accurate resident population with mental health and substance abuse diagnosis. Findings include:Review of facility policy 'Facility Assessment,' updated July 14, 2025, states that the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. The assessment is used to make decisions about direct care of staff needs, as well as capabilities to provide services to the residents in facility. The facility assessment is used to ensure that each resident is provided with care that allows the resident to maintain or attain their highest practicable physical,…

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 with residents and staff, it was determined that the facility failed to provide a safe, clean and homelike environment for three of four nursing units observed (B, C and D units).Findings include: Interview on April 28, 2026, at 9:29 a.m. Resident R1 stated that the room was in disrepair, including broken furniture, soiled and broken privacy curtains, soiled walls and broken baseboards. Observation, at the time of the interview, of room B16, revealed the following: The dresser for bed 1 was tattered and worn; the dresser for bed 3 was also tattered and had broken drawer handles; the air conditioning unit in the room had insulation that was falling out, creating an opening that would allow pests and debris to enter the room; the air conditioning unit's filter was caked with dirt and debris; the baseboard behind bed 1 was peeling away from the wall and exposing a hole that would allow pests and debris to enter the room; the wall behind bed 3 was soiled with a brown substance; the privacy curtain for bed 3 was soiled, torn and unable to close…

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

Based on review of facility documentation, observations, and staff interview it was determined that the facility failed to ensure food was stored and prepared in accordance with standards for food service safety. Findings Include: Review of facility policy Food Storage revealed temperatures for the freezer should be 0 degrees or below and must be recorded daily. A tour of the main kitchen was conducted on June 2, 2025, at 10:00 a.m. with the Food Service Director, Employee E27, which revealed the following: Observations in the outbuilding containing the walk-in freezer revealed a steel entry door that was not closed properly, and the bottom of the door was rusted through and did not seal. There was significant dirt and debris built-up within the outbuilding containing the walk-in freezer. Observations inside the walk-in freezer revealed it had a significant build up of ice on the outside of the fan and ceiling. The hot dogs and bread were not frozen solid to touch which indicated that these food items had began to defrost. The thermometer on the outside of the freezer was reading 32…

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

Based on observations, interview with staff and residents, it was determined facility did not ensure the facility was maintained in a clean, safe, and homelike environment on two out of four nursing units observed (A-wing, C-Wing, D-Wing, and Dining Room). Findings include: Review of facility policy 'Quality of Life - Homelike Environment,' revised May 2017, indicates that the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, home-like setting. The characteristics include: a.Clean, sanitary and orderly environment; e. clean bed and bath linens that are in good condition Observations on Monday, June 2, 2025 at 10:00 am, on wing C, revealed gnats in room C-12, as well as used cups, excess food crumbs on floor, dirty bedside tables, used utensils and used apple sauce cups on bed side tables. Room C-12 was noted to have foul urine odor. Further observations on wing-D, near room D-19, revealed a large bin with used breakfast cups/plates, gnats. Further observations in room D-21 revealed used portable…

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

Based on review of facility documentation, observations, and resident interviews it was determined that the facility failed to serve meals timely for one of three dining observations (June 3, 2025, breakfast meal). Findings Include: Review of facility documentation Mealtimes revealed breakfast is scheduled to be served at 8:00 a.m. Observations on June 3, 2025, at 9:26 a.m. revealed seven residents were still waiting for breakfast to be served. Resident R20 and R36 complained of being hungry. Observations on June 3, 2025, at 9:30 a.m. revealed dietary staff just began to plate meal trays from the steam table in the 1st floor dining room. Interview with the Registered Dietitian, Employee E8, confirmed breakfast was late due to dietary employees not showing up for work. Interview on June 3, 2025, at 11:30 a.m. during the group meeting with alert and oriented Resident R20, R29, R40, and R22 revealed meals are not served in accordance with posted meal times which reportedly interferes with being able to develop a consistent routine for residents. 28 Pa. Code 201.14 (a) Responsibility 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 and interview with staff and residents as well as review of facility provided documentation, it was determined facility did not ensure to maintain effective pest control program on two out of four units observed (Units, A, C, and D). Findings include: Review of facility policy 'Pest control,' revised May 2008, indicates that facility shall maintain an effective pest control program, and garbage and trash are not permitted to accumulate and are removed from facility daily. Maintenance services assist, when appropriate and necessary, in providing pest control services. Observations on Monday, June 2nd,2025, at 10:00 am, C-unit, revealed excess trash, gnats, food crumbs in room C-12; used cups, used apple sauce cups, dirty bed side tables, used utensils. Further observations on C-unit revealed a large bin near room D-19, with used breakfast utensils, cups and plates with gnats flying around. Further observations revealed excess trash on floor in room D-26. Further observations on D-unit,…

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

Based on review of clinical record, observations, and staff interview it was determined that the facility failed to maintain dignity for one of eight residents during dining (Resident R70). Findings Include: Review of Resident R70's physician order summary revealed a diet order dated April 7, 2025, that the resident was NPO (nothing by mouth for food or drinks). Review of Resident R70's comprehensive care plan dated April 16, 2025, revealed the resident was allowed pudding or applesauce at lunch time only with specific feeding instructions. Continued review of Resident R70's comprehensive care plan dated December 16, 2024, revealed the resident was dependent on staff for eating, dressing, and mobility. Observations on June 4, 2025, at 12:45 p.m. revealed Resident R70 was in the 1st floor activity room sitting in a geri chair (specialized medical recliner) surrounded by about 5 other residents who were consuming lunch. Resident R70 did not have any pudding or applesauce provided during dining. Interview on June 4, 2025, at 12:45 p.m. with Nurse Aide, Employee E20, confirmed 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 review of facility policy, review of clinical records, observation, and staff interviews it was determined the facility failed to ensure that residents were free from neglect for one of 8 residents reviewed relating to one employee not providing supervision and care for one resident over a period of two scheduled shifts.(resident R16) Findings include: Review of policy titled Abuse Prevention program dated January 1st, 2022, revealed residents have the right to be free from abuse common neglect, misappropriation of resident property and exploitation. This includes neglect which is defined as a failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. The following are some examples of neglect and signs and symptoms of neglect that should be promptly recorded reported some signs of neglect are dehydration, poor hygiene, inappropriate clothing, inadequate provision of care, caregiver indifference to resident's personal care and needs, leaving someone unattended who needs supervision. Review of facility documentation…

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 interview with residents and staff as well as review of clinical records, it was determined facility did not develop and implement a comprehensive resident centered care plan related to maintaining resident's hearing and nutrition for one of 19 residents reviewed (Resident R25) Findings include: Review of facility's policy Care Plans, Comprehensive Person-Centered, revised March 2022, indicates that the comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and c. reflects currently recognized standards of practice for problem areas and conditions. Review of resident R25's clinical record revealed an [AGE] year old male resident, awake, alert and oriented to self only, with medical diagnosis of psychomotor deficit (impaired motor function accompanied by cognitive or mental slowing), and cognitive communication deficit (difficulty with communication due 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 and review of clinical records, it was determined facility did not maintain proper grooming and personal hygiene for two of 19 residents reviewed (Resident R26, R52) Findings include: Review of facility's policy 'Activities of Daily Living (ADL's) , Supporting,' revised March 2018, indicates that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Further review of policy indicates that if residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. Review of R26's clinical record revealed an [AGE] year old male resident with medical diagnosis of need for assistance with personal care,…

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

Based on interview with staff and resident, as well as review of clinical records, it was determined facility did not ensure that resident received proper treatment and assistive device to maintain hearing abilities for one of 19 residents reviewed (Resident R25) Findings include: According to §483.25(a)(2) - Assistive devices to maintain hearing include, but are not limited to, hearing aids, and amplifiers. The facility's responsibility is to assist residents and their representatives in locating and utilizing any available resources (e.g., Medicare or Medicaid program payment, local health organizations offering items and services which are available free to the community) for the provision of the services the resident needs. This includes making appointments and arranging transportation to obtain needed services. In situations where the resident has lost their device, facilities must assist residents and their representative in locating resources, as well as in making appointments, and arranging for transportation to replace the lost devices. Review of R25's clinical record…

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

Based on observations, review of facility policies and interviews with staff it was determined that the facility failed to maintain a safe environment free from accident hazards for one resident related to hazardous material endangering the environment and welfare for two of two residents reviewed. (Resident R44 and R68) Findings include: Review of facility policy titled Quality of Life - Home like Environment revised May 2017, revealed residents are provided with a safe, clean, comfortable in home like environment and encourage to use their personal belongings to the extent possible. Review of residents R 44's quarterly minimum data set (MDS - a federal mandated assessment tool for all residents) dated February 21st, 2025, revealed that the resident entered the facility June 11, 2024, with diagnosis including cerebrovascular Accident (CVA_ stroke) and dementia (loss of cognitive function) with a brief interview of mental status (BIMS) score of three indicating significant cognitive decline. This resident requires substantial assistance for hygiene, toileting, dressing, sit to stand…

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 staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for residents past experiences and preferences in order to eliminate and or mitigate triggers that may cause re- traumatization of the resident for two of two residents sampled. (Residents R28 and R30) Findings include: Review of facility policy titled Trauma Informed Care revealed guidelines for implementing trauma informed care in long term care facilities to support residents and staff who may have experience trauma. The goal is to provide care that is safe, respectful, and responsive to the effects of trauma while fostering a supportive environment. Care will be provided in a manner that prevents retraumatization and promotes healing and empowerment . This will be done through staff training, resident assessment and care planning, to develop individual care plans that account for trauma related needs, preferences and triggers , implement measures to minimize…

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

Based on review of facility documentation, observations, and staff and resident interviews it was determined that the facility failed to serve the posted menu for one of three dining observations (June 2, 2025, lunch meal). Findings Include: Observations on June 2, 2025, at 1:00 p.m. revealed the posted lunch menu was a pork chop topped with apple marinade. Furter observations on June 2, 2025, at 1:00 p.m. revealed Resident R20 was served a plain pork chop without any gravy or marinade. Resident R20 subsequently requested gravy for the pork chop. Interview on June 2, 2025, at 1:05 p.m. with Activity Aide, Employee E23, confirmed what was on the posted menu and further confirmed Resident R20 did not get gravy on the pork chop. Activity Aide, Employee E23, went to kitchen for gravy but reported that the kitchen did not have any. Interview on June 2, 2025, at 1:35 p.m. with the Cook, Employee E24, confirmed the apple marinade was not served with the pork for lunch per the posted menu, Further interview revealed there was no applesauce left to use for medication pass and therefore…

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 provided documentation, observations , and interview with staff, it was determined facility did not use its hoursekeeping resources effectively and effeciently to provide services in compliance with accepted professional standards and principles that apply to professionals providing services in the facility related to housekeeping services. Findings include: Review of facility's assessment indicates that the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Facility assessment is to be used to make decisions about facility's direct care staff needs, as well as capabilities required to provide services to the residents in facility. Further review of facility's assessment indicates that using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable, physical, mental, and psychosocial…

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 interview with staff and residents, it was determined facility did not implement and maintain an effective infection prevention control program related to water management, meal service and hygiene care for one of 19 residents reviewed (Resident R25) Findings include: Review of facility policy 'Infection Prevention and Control Program,' revised October 2018, indicates that important facets of infection prevention include instituting measures to avoid complications or dissemination. Further review of policy indicates that the infection preventionist or designee shall monitor the effectiveness of our infection prevention and control work practices and protective equipment. This includes but is not necessarily limited to: a. surveillance of workplace to ensure that established infection prevention and control practices are observed and protective clothing and equipment are provided and properly used. Interview with resident R25 on Monday, June 2nd, 2025, at 10:30 am, revealed his concern of clogged sink in his restroom, stated that it has been clogged for 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.

The facility failed to maintain essential kitchen equipment in safe, operating condition. Findings Include: Review of facility policy Food Storage revealed temperatures for the freezer should be 0 degrees or below and must be recorded daily. A tour of the main kitchen was conducted on June 2, 2025, at 10:00 a.m. with the Food Service Director, Employee E27, which revealed the following: Observations inside the walk-in freezer revealed it had a significant build-up of ice on the outside of the fan and ceiling. The hot dogs and bread were not frozen solid to touch which indicated that these food items had begun to defrost. The thermometer on the outside of the freezer was reading 32 degrees Fahrenheit (F), and the thermometer on the inside of the freezer was reading 28 degrees F. Per an interview with the Food Service Director, Employee E27, the morning cook had reported that the freezer temporarily turned off. The facility had no log or documentation to show the ongoing monitoring of the freezer temperature and its components. Observations of the dish machine revealed when in 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 review of facility policy, clinical record review and interviews with staff, it was determined that the facility failed to ensure a Level ll PASARR was conducted for residents with mental disorders as required for four of four residents reviewed. (Residents R1, R3, R20 and R36). Findings include: Review of facility policy titled Patient Access to Service and Record (PASR) Policy, not dated, revealed that the purpose of The PASARR screening is to ensure that individuals with mental illness and or intellectual disabilities are appropriately evaluated and placed in skilled nursing facilities with access to necessary services in compliance with federal and state regulations. Further review of the facility policy revealed the process of the PASARR evaluation begins with a preadmission screening, all prospective residents will undergo a PASARR screening prior to admission, if an individual level 1 screening indicates a potential mental illness, a level ll evaluation will be completed. admission to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Review of clinical record, review of facility policy and interview with staff, it was determined that the facility failed to ensure that residents were provided with education regarding the benefits and potential side effects of influenza immunization for three of three residents (Residents R85, R8 and R17). Findings: Review facility policy on Influenza Vaccine revealed that under Section Policy Statement, all residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccination against influenza. The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents or residents legal representatives. For example, risk factors that have been identified for specific age groups or individuals with risk factors such as such as allergies and pregnancy. Under section Policy Interpretation and Implementation. #1 Between October 1st 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 observations and staff interviews, it was determined that the facility failed to ensure a safe, functional, and sanitary environment for residents, staff, and the public on four out of four nursing units. (A, B, C, D nursing units) Findings include: On July 29, 2024, from 10:33 a.m. to 11:06 a.m. observations were conducted on the D unit revealed the following: Room D15 had no baseboard from the door to the bedside dresser, the room had a strong urine smell and sticky floors. Room D25 bed by the window had a missing shelf from the dresser, large, ripped cardboard box was on the floor with the box being overloaded with random resident's items in the box. Room D14 window bed had boxes and random bags on the floor which cluttered the pathway to get around the resident's rooms. Room D17 there was stool in the bathroom floor and all around the toilet, the bed next to the door had no baseboard from the door to the bed dresser. The room had sticky floors, strong stool smell in the room. Resident's closet did…

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, reviewof clinical records, facility documentation, staff and resident interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 18 residents reviewed (Resident R137). Findings include: A review of the clinical record indicated Resident's R137 was admitted to the facility on [DATE] with the diagnoses of severe intellectual disability (previously known as mental retardation characterized by limitation in intellectual functioning and adoptive behavior), restlessness and agitation, psychotic disorder with delusion, autism (autism spectrum disorder known as developmental disorder and effects communication, behaviors and social interaction), mood disorder. Review of Resident R137's Minimum Data Set (MDS - a periodic assessment of care needs) dated May 22, 2024, revealed a Brief Interview for Mental Status (BIMS) of 10 which indicated that the resident was moderate impairment. A facility investigation dated June 5, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, resident and staff interviews and review of facility policy, it was determined that the facility failed to conduct a complete and though investigation to rule out abuse related to one of one allegation of potential sexual abuse. (Resident R11) Findings include: Review of facility policy titled Abuse Prevention Program dated January 1, 2022, revealed the primary purpose of the policy is for the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The following implementations are indicated in the prevention program; Separate the residents, identify what happened, notify each resident's representative of the incident ;review the events with the Nursing Supervisor and Director of Nursing, consult with the Attending Physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem; make any necessary changes in the care plan approaches to any or all of the involved…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility failed to ensure that the environment remained free of accident hazards for one out of the 37 residents reviewed and had residents would have appropriate supervision. (Resident R30) Findings include: A review of the clinical record indicated Resident R30 was admitted to the facility on [DATE] with the following diagnosis schizophrenia ( chronic and severe mental disorder which includes hallucination, delusion, disorganized thinking, agitation or erratic behaviors) and major depressive disorder (feeling sadness, loss of interest, significant change in weight or appetite, feeling of worthlessness, difficult concentrating or making decisions). Review of Resident R30's Minimum Data Set (MDS - a periodic assessment of care needs) dated May 3, 2024, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was cognitively intact. A comprehensive care plan was developed on June 9, 2022 which revealed 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 clinical record review and staff interview, it was determined that the facility failed to ensure that a resident's medication regime was free from potentially unnecessary medications for one of four residents reviewed (Resident 68). Findings include: Facility policy titled Policy for Psychotropic Use in Long-Term Care (LTC), indicated that The facility will adhere to all relevant federal, state, and local regulations regarding the use of psychotropic medications in LTC settings. Clinical record review revealed Resident R68 was admitted to the facility February 09, 2022, with a diagnosis that included but not limited to Cerebral Infarction (disruption of blood supply to the brain that causes brain tissue death), Schizophrenia (mental health condition that affects how people think, feel, and behave), and Altered Mental Status. Review of Resident R68's medication orders revealed a physician order initiated June 28, 2024 to administer Ativan 0.5 mg (anti-anxiety medication) orally (by mouth) every four hours as needed for anxiety. The medication order indicated a stop date 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, review of facility policy, observation, and staff and resident interviews, it was determined that the facility failed to ensure that all drugs and biologicals are stored and labeled in accordance with professional standards. For one of eighteen residents reviewed. (Resident R40). Findings include: Review of the facility policy and storage of medication revealed that under section policy statement, the facility stores all drugs and biologicals in a safe, secure and orderly manner under section Policy Interpretation and Implementation #1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. #3 The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. #4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. #8 compartments, including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observations and staff interviews, it was determined that the facility failed to assess the need for specialized occupational therapy services according to the professional standards of practice for one out of one resident reviewed for rehabilitation services (Resident R18). Findings include: Review of facility policy Standards and Guidelines: Restorative Nursing Services dated August, 2022, revealed that To promote the resident's optimum function, a restorative nursing program may be developed by proactively identifying, care planning, and monitoring of a resident's assessments and indicators, Restorative nursing program refers to interventions that promote the resident's ability to adopt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental and psychosocial functioning. Restorative programs may be initiated by nursing and/or therapy. A review 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 review of facility documentation and staff interview it was determined that the facility failed to ensure a designated infection prevention (IP) works at the facility focusing only on infection control at least part time as required one or more individuals servicing as infection Preventionist responsible for the facility's infection prevention plan. Finding include: Review of facility documentation identified the Director of Nursing (DON) fulfilled the job of Infection Preventionist. The DON works full time and was unable to provide valid proof that additional part time hours focusing only on infection control were completed in addition to his/her full time DON duties. Review of the Infection preventionist (IP) job description revealed that the IP is responsible for the activities aimed at healthcare associated infections. The responsibilities include collecting, analyzing health data, and interpreting, implementing, and evaluating public health practices. The IP will conduct education and training on healthcare associated infections for staff and management. Interview 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.

Based on observations of the food and nutrition department, and interview with staff, it had been determined that the facility failed to maintain essential food service equipment in a safe operating condition relating to a gas stove control knobs and kitchen exhaust fan. Findings Include: Review of facility policy titled Supplies and Equipment, Environmental Services revised February 2009, revealed equipment must be always ready for use at all times. An initial tour of the main kitchen conducted on July 29, 2024, at 09:35 AM with employee E 25 with Dietary director, revealed the facility had five refrigerators, four are functioning and one is out of order, and a gas oven/ grill with no knobs to be used for igniting the flame and controlling the amount gas to the range for temperature adjustment. Interview with Employee E17 on July 30, 2024, at 8:10 a.m. during breakfast preparation revealed that for an individual to use the stove without any knobs, in the kitchen there is a plastic knob on the shelf to be placed over the valve and turn. Employee E17 then demonstrated the knob, which…

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 staff and resident interviews, it was determined that the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature (second floor nursing unit). Findings Include: Interview with Resident R2, on April 30, 2024, at 11:30 a.m. revealed that the meat consistency is too chewy. I cannot swallow any of the meat because it is a weird texture. Interview with Resident R1, on April 30, 2024, at 12:00 p.m. revealed that the protein source (meat) served at the facility is very tough to chew. Interview with Resident R3, on April 30, 2024, at 12:30 p.m. revealed that the meat served for lunch is tough. Observations of dining conducted on the second-floor dining room, on April 30, 2024, at 1:00 p.m. revealed that the burger patty melts (beef patty covered with melted cheese) were pink in color and appeared undercooked. Interview with the Director of Nursing at time of observation confirmed this observation. Interview with the server, Employee E5, at the time of observation confirmed that the beef patties were pink in color…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, reviews of clinical records and review of facility policies and procedures, it was determined that the facility failed to provide adequate treatment, assessment and monitoring for the care and maintenance of an intravenous catheter in accordance with professional standards of practice for one of 7 residents reviewed (Resident CL1). Findings include: According to the standards of nursing practice guidelines in the Journal of the American Nurse's Association, dated November 2013, complications of a PICC line includes, but is not limited to catheter-tip migration (assessed by external length of the catheter-amount of catheter tubing that is visible outside of the vein moves from original insertion and may cause medical complications). Review of facility policy, Peripherally Inserted Central Catheters, revised May 18, 2020, indicated that the medical doctor must be notified immediately if changes in the length of the catheter exiting from the insertion site occurs. Review of Resident CL1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, reviews of policies and procedures and interviews with staff, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for skin alterations and skin disorders for one of three residents reviewed. (Resident Cl1) Findings include: A review of the facility policy titled comprehensive person-centered care plans, dated March 2022 revealed that the interdisciplinary care team was responsible for development of a care plan for each resident with measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The resident and his/her family or legal representative was to participate in the care planning process. The care plan was to describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Care plan interventions were required to address the underlying source of the problem areas not just the symptoms or…

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