River's Edge Rehabilitation & Healthcare Center

Based on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for six of 24 residents reviewed (Residents R3, R8, R12, R44, R80, and R112).Findings include: A review of facility policy titled food temperatures, undated, revealed foods will be served at the proper temperature to ensure food safety, Acceptable serving temperatures are: Meat, entrees- greater than 135 degrees but preferably 160 degrees to 175 degrees; potatoes greater than 135 degrees; vegetables greater than 135 degrees. Interview with Resident R112 on March 23, 2025, at 7:45 p.m. revealed food is always cold when it is served, it sits on the carts too long and it just doesn't stay hot. Observations during a test tray conducted on March 24, 2025, at 12:45 p.m. revealed that the last tray was passed at 12:45 p.m. Temperatures were taken by the Food Service Director (FSD), Employee E11, which revealed that the hamburger served was only 130 degrees Fahrenheit (F),…

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 January 29, 2026, revealed there was no indication that the facility involved direct care staff, input from residents, resident representatives, and/or family members. Interview with the Administrator, Employee E1, on March 25, 2026, at 12:00 p.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 a review of clinical records, facility documents, and staff interview, it was determined that the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not) for three of five residents reviewed (Resident R135, R126, R7). Findings include: Review of Resident R135 revealed the resident was admitted to the facility on [DATE] with a diagnosis of disorder of kidney and ureter ( kidneys or the tubes that carry urine from the kidneys to the bladder are not working properly, which can affect how the body filters waste and removes urine), cerebrovascular disease (condition that affects the blood vessels in the brain, reducing blood flow and potentially causing brain damage, such as a stroke), and anxiety disorder. Review of Resident R135's Brief Interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for three residents reviewed who had a indwelling Foley catheter, wound and internal feeding tube. (Residents R6, R91, and R108).Based on a review of the facility's Infection Control requirements Influenza Vaccine for Unvaccinated Healthcare workers to be wearing a mask, the facility failed to ensure that unvaccinated healthcare workers are wearing a mask. Specifically, vaccinated record for one Licensed Practical Nurse, who refused the Influenza Vaccine was not wearing a mask. Findings Include: According to the facility policy titled Influenza Vaccine (reviewed December,2025) number 11, the use of source control for unvaccinated health care workers will be based on state guidelines or outbreak status. On the Mask Acknowledgement form, it states that during influenza season a surgical mask will be worn during direct resident contact, in common areas of the…

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

Based on observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings include: Review of facility policy, Food Storage undated, revealed, Food items will be stored, thawed, and prepared in accordance with good sanitary practice. Continued review revealed, All products shall be dated upon receipt or when they are prepared. Use Date shall be marked on all food containers . and all cooked meat shall be used within 3-4 days. A tour of the main kitchen was conducted with the Food Service Director (FSD), Employee E6, on March 25, 2025, at 10:05 a.m. Observations in the main refrigerator revealed two 10-pound ground beef links were unlabeled and undated; opened ham deli meat was dated March 10, 2025; two 10-pound ready to eat roast beef labeled with a received date March 17, 2025; and opened mozzarella cheese labeled with a recieved date December 10, 2024. Observations of the three-compartment sink revealed Dietary…

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

Based on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Findings include: A tour of the main kitchen was conducted with the Food Service Director (FSD), Employee E6, on March 25, 2025, at 10:05 a.m. revealed the following: Observations of the receiving area and loading dock, that are used by the facility to transport clean food, revealed hundreds of cigarette buds. Further observations revealed the garbage was not covered. Interview with Food Service Director, Employee E6 along duration of the tour confirmed observations of the receiving and dumpster area. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility

Based on staff interview and review of clinical records, it was determined that the facility failed to ensure that care plan meetings were held for one of 24 residents reviewed. (Resident R55) Findings include: Review of Resident R55's person-centered plan of care indicated that the resident exhibited a decline in communication due to hearing deficit and impaired cognition and thought process related to diagnoses of dementia. Review of Resident R55's clinical records revealed a nursing note dated June 3, 2024, which indicated, care conference meeting was held and that the resident's daughter in law attended via phone. Further review failed no documented evidence of care conference meetings occurred after June 2024. Interview with the facility Administrator and Social Worker, Employee E8, conducted on March 27, 2025, at 10:55 a.m. confirmed that the last care conference was conducted in June 2024 with resident and their representative. Further interview confirmed that the facility failed to conduct a care conference meeting with Resident R55 and their representative in September 2024…

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

Based on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer to the hospital in a timely manner, in writing and in a language and manner they understood for two of 24 residents reviewed for hospitalizations (Residents R31 and R102). Findings Include: Review of nursing notes for Resident R31 dated November 20, 2024, at 11 p.m. revealed that the resident was admitted to the hospital with diagnosis of hematoma of the left kidney and abdominal pain. Further review revealed a note, dated on October 25, 2024, at 2:42 p.m. revealed that Resident R31 was discharged home. Review of nursing notes for Residents R102 dated March 20, 2025, at 4:35 p.m. revealed that resident was transfer to hospital for evaluation of gastro intestinal bleed. Review of clinical record revealed no evidence that Residents R31, R102, R27 and R99 representatives were notified of the transfer to the hospital and the reasons for the transfer 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 review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement treatment and services for incontinence management for one of 24 residents reviewed.(Resident R11). Findings include: Review of physician order for Resident R11, dated March 24, 2025, indicated an order to change unrinary Foley Catheter with size 16fr/10ml; change monthly, and as needed, based on clinical indications such as infection, obstruction, or when the closed system is compromised, every night shift, every 4 weeks on Tuesdays, and as needed. On March 27, 2025, at 1:00 p.m., it was observed that Resident R11 had a Foley Catheter of 16fr/5ml Balloon, instead of the physician ordered size of 16fr/10ml Balloon. At the time of the finding, confirmed the same with a Licensed Nurse, Employee E5. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed to monitor and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for two of four residents reviewed for nutrition (Resident R35). Findings Include: Review of facility policy titled, Weight Loss indicated that any resident displaying a significant change in weight of greater than or equal to 5% gain/loss in one month will be reweighed. Review of facility policy Supplementation dated January 2025 indicated that if an increase in caloric or protein needs are identified, the Dietitian will determine which supplements are appropriate to meet the specific resident's needs. Further review indicated that Residents may benefit from a therapeutic supplement if the present with decreased PO intakes and unplanned weight loss. Review of Resident R251's quarterly Minimum Data Set (MDS - federally mandated resident assessment 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 clinical record review, staff interview and review of facility policy, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address a resident's dementia care needs for one of 24 residents reviewed (Resident R84). Findings Include: Reviewed facility dementia policy title Care Plan dated in September 2024 states that the plan of care shall be individualized to and based upon, the assessment and diagnosis of a resident. Review of the admission sheet of Resident R84, revealed that Resident R84 was admitted to the facility on [DATE], with the diagnosis of Dementia (Dementia is not a specific disease but is rather a general term for the impaired ability to remember think, or make decisions that interferes with doing everyday activities). Review the care plan dated April 21, 2022, revealed that of Resident 84's care plan revealed no care plan with measurable goals and interventions to address the care and treatment need related with dementia 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 staff interviews and clinical record reviews, it was determined that the facility failed to ensure that mattresses and bed frames that were purchased separately were compatible with each other for one of 24 residents reviewed (Resident R99). Findings include: Observations of Resident R99's bed conduced on March 24, 2025, and March 25, 2025, revealed that the mattress appeared six inches smaller than the metal bed frame; the bedframe slats were exposed on each side. Increased entrapment concerns were observed. Review of the admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 99, dated October 9, 2024, revealed that the resident was admitted to the facility with diagnoses including neurological conditions, cerebrovascular accident (stroke), cognitive communication deficit, muscle weakness and atrophy. Interview with the Nurse Assistant, Employee E4, conducted don March 24, 2025, at approximately 12:20 p.m. confirmed that Resident R99 had been utilizing the current bed frame and mattress since admission.…

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 staff, it was determined that the facility failed to follow physician orders related to medication administration for two of 13 residents reviewed (Residents R3 and CL2). Findings Include: Facility Policy titled, Medication Administration Policy updated, January 2024 revealed under procedures J. Medication Administration 8. Ensure that the customer swallows all the medication(s). Medication Times BID (Twice a Day) = 0900-1700, TID (Three Times a Day) 0900-1300-2100, QID (Fourt Times a Day) =0900-1300-1700-2100; Before Meals=0600-11:00-1630, After Meals= 0900-1300-1800. Review of the resident's clinical record indicated resident R3 was admitted on [DATE], with the diagnosis of type 2 diabetes mellitus (a chronic condition that affects the way your body processes blood sugar) with diabetic neuropathy, (nerve damage associated with diabetes), morbid severe obesity. A review of the physician order dated May 24, 2024, indicated 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 staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that residents and /or their responsible parties were provided with the opportunity to participate in their care plan meetings for 4 out of 27 residents reviewed (Residents R64, R54, R85 and R69). Findings include: Review of the policy, Resident/patient/Family Care Plan Conferences, with a revision date of August 2023, indicated that it was the policy of the facility to ensure that the resident and his/her family and legal representative are part of the interdisciplinary team and participate in the development and ongoing review of the interdisciplinary plan of care. The policy also indicated that the resident/responsible party will be notified of the care plan conference and that that the method of documentation will be documented in the medical record. Review of the clinical record for Resident R64 indicated that he resident's last care plan meeting was on held on February 13, 2023. Review of the clinical record for Resident R54 indicated…

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

Based on staff interviews, review of facility policy and the review of the clinical record, it was determined that the facility failed to ensure that a physician was notified of a resident's refusal to take prescribed medication for 1 out of 27 residents reviewed (Resident R39). Findings include: Review of the facility's undated policy, Medication/Order Availability indicated that it was written to ensure that all residents have medications/orders administered as ordered. The policy also indicated that medications/orders are to be administered by physician order. Review of the physician orders for Resident R39 included the diagnoses of history of falling; hypertension (high blood pressure); seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in an individual's behavior, movements, feelings, and consciousness). and diabetes (a chronic condition that happens when you have persistently high blood sugar levels). Review of Resident R39's May 2024 physician orders included a physician's order for the medication, Lantus (a medication prescribed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of facility policy, review of clinical records and facility reports, it was determined that the facility failed to ensure a complete and through investigation for bruises of unknown origin for 1 out of 27 residents reviewed (Resident R69). Findings include: Review of the facility Abuse, Neglect and Exploitation, policy with a review date of March 2024 indicated that the facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents including, but not limited to: resident staff or family report of physical abuse; resident report of theft of property or missing property; psychological abuse of the resident observed, physical injury of a resident, of an unknown source. Review of Resident R69's May 2024 physician orders revealed the diagnoses of pain; delusional disorder (the individual has firmly held false beliefs); hypertension (high blood pressure) and peripheral vascular disease (a common condition in which narrowed arteries reduce the blood flow…

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, clinical record reviews, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers as required for four of four records reviewed related to hospital transfers (Residents R86, R23, R83 and R92). Findings include: Review of facility documentation, Hospital Tracking Portal received June 3, 2024, revealed that 21 residents were transferred to the hospital during February 2024, 18 residents were transferred to the hospital during March 2024, and 17 residents were transferred to the hospital during April 2024. Review of progress notes for Resident R86 revealed a note, dated February 11, 2024, at 6:48 a.m. which indicated that the resident was transferred to a local hospital emergency department via 911 due to a swollen tongue. Review of progress notes for Resident R23 revealed a note, dated March 20, 2024, at 10:43 p.m. which indicated that the resident had low blood sugar and was ordered by the physician to be transferred to a local…

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

Based on observation, staff interviews, review of resident records and facility policy, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for three of 27 resident records reviewed (Residents R40, R62, and R65). Findings include Review of the facility's care plan policy reviewed January 2023 states, All residents admitted to the facility will have adequate person centered care plan that provide for all their needs in a timely manner. Review of Resident R40's physician order dated December 11, 2023, instructed to administer oxygen at 2 liters a minute via nasal cannula as needed for shortness of breath. Further orders instructed to clean the O2 (oxygen) concentrator filters on Thursdays during the 11-7 shift and as needed. Review of Resident R62's physician order dated April 30, 2024, instructed to administer oxygen at 2 liters a minute via nasal cannula continuously for shortness of breath. Further orders instructed to clean the O2 concentrator filters on Thursdays during the 11-7 shift and as needed. 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 observations, review of clinical records, and staff interviews, it was determined that the facility failed to ensure a physician order for neurology was followed for one of 27 residents reviewed (Resident R62). Findings include: Review of Resident R62 clinical records revealed the resident was transferred to the hospital for right arm weakness. Review of the hospital discharge instructions dated April 30, 2024, indicated a follow up with neurology was to be made in two weeks. Further review of the resident's clinical record revealed no documented evidence the neurology appointment was scheduled. This finding was confirmed with the Unit Manager on June 3, 2024, at approximately 2:15 p.m. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, observations, record review, and staff interviews, it was determined that the facility failed to provide respiratory care services consistent with professional standards of practice for three of 27 residents reviewed, (Residents R40, Resident R62, Resident R65). Findings Include: Review of facility policy for Oxygen Administration revised in January 2024 indicates the purpose of this policy it to safely administer oxygen to the resident. Nursing staff will be responsible the correct administration of oxygen. The same policy states when a concentrator is used to wash the filter weekly. Review of Resident R40's physician order dated December 11, 2023, instructed to administer oxygen at 2 liters a minute via nasal cannula as needed for shortness of breath. Further orders instructed to clean the O2 concentrator filters on Thursdays during the 11-7 shift and as needed. Review of Resident R62's physician order dated April 30, 2024, instructed to administer oxygen at 2 liters a minute via nasal cannula continuously for shortness of breath. Further orders…

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, and staff interviews, it was determined that the facility failed to ensure the accurate acquiring, receiving, and administration of medications to meet the needs of each resident for one of 27 residents reviewed (Resident R56). Findings Include: Review of facility policy Medication/Order Availability (undated) revealed all residents should have medications/orders administered as ordered. Per review of facility policy, in the case a medication/supply is not available, and to ensure comparable alternative is provided, staff should implement the following procedures: 1. Medication/orders are to be administered per MD order 2. If medication/supply is not available in the facility, MD is to be notified 3. Resident's plan of care is to be reviewed and suggested alternative ordered and provided. 4. Order to be updated accordingly in PCC to reflect any change 5. Discuss any change in order with IDT involved in plan of care Resident R31 was admitted 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 records, and staff interview, it was determined that the facility failed to obtain laboratory services to meet the needs of one resident's digoxin levels per physician orders of 27 residents reviewed (Resident R55). Findings include: Review of Resident R55 clinical record revealed the resident was admitted to the facility on [DATE], diagnosed with Atrial Fibrillation (irregular often fast heartbeat). Review of physician orders revealed the resident was ordered the medication Digoxin to treat the resident's Atrial Fibrillation. Review of Resident R55 clinical record revealed a plan of care for Digoxin therapy that included goals that the resident would be free from discomfort or adverse reactions related to digoxin use. Interventions included serum digoxin levels monthly or as ordered by the physician and to report to the physician, suspect toxicity if anorexia, nausea, vomiting diarrhea and visual disturbances occur initiated in March 2020. Further review of Resident R55 physician…

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 policies and procedures and interviews with staff, it was determined that the facility failed to promptly notify a resident's representative of a new pressure ulcer for one of three residents reviewed for pressure ulcer prevention. (Resident R1). Findings include: 1. Review of facility policy titled Change in a Resident's Condition or Status dated, November 2019, revealed 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument and 42 CFR 483.20(b)(ii). 4. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet care needs for one of three residents reviewed. (Resident R1) Findings include: Review of an undated facility policy titled, Pressure Ulcer Prevention/Management Program indicated that To provide a standardized action in the management of, and to aid in the prevention or the development of, pressure ulcers. The interdisciplinary team will discuss the evaluation, and a specific individualized plan of care will be developed to address the resident's needs and risk factors in accordance with nursing standards of practice. Review of admission nursing assessment dated [DATE], revealed tat the resident was using heel boots for prevention of skin issues. Review of Resident R1's Minimum Data Set assessment (MDS- assessment of a resident's abilities and care needs) dated October 17, 2023, identified that the resident did not have a pressure ulcer/injury…

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, and interview with staff and residents, it was determined that the facility failed to develop and implement an effective discharge planning process including the resident's discharge goals and information to the resident's representative of the final plan upon resident's discharge for one of three resident reviewed. (Resident R1) Findings Include: Review of Resident R1's Minimum Data Set assessment (MDS- assessment of a resident's abilities and care needs) dated October 17, 2023, identified that the resident did not have a pressure ulcer/injury (Injury to skin and underlying tissue resulting from prolonged pressure on the skin), a scar over bony prominence, or a non-removable dressing/device. Review of wound care consult report dated November 2, 2023, revealed that the resident has unstageable pressure ulcers (ulcer involving loss of skin layers exposing muscle) to right and left heel which was not present on admission. Resident was ordered to receive Honey gel and…

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

Based on clinical record review, and interviews with staff, it was determined that the facility failed to follow physician order as ordered by the physician for one of three residents reviewed (Resident R1). Findings Include: Review of clinical record for Resident R1 revealed that the resident was admitted to the facility with diagnosis including Heart Failure and Chronic Kidney Disease. Review of physician order for Resident R1 dated October 11, 2023, revealed an order for daily weight and to notify the physician with weight gain of 2 pounds in one day or 5 pounds in 3 days. Further review of physician order dated October 11, 2023, revealed an order to give Lasix (It can treat fluid retention (edema) and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions) 40 milligrams one tablet by mouth as needed for weight gain of 2 pounds in one day. Review of Medication Administration Record for Resident R1 for the month of October 2023 revealed that on October 28, 2023, resident weighed 154.5 pounds and on October 29, 2023, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of clinical records, staff interviews, it was determined that the facility failed to ensure that a physician's wound care recommendations to promote the healing of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) were followed as ordered and failed to ensure that the pressure ulcer prevention interventions were consistently implemented for one of three residents reviewed (Resident R1). Findings include: Review of an undated facility policy titled, Pressure Ulcer Prevention/Management Program indicated that To provide a standardized action in the management of, and to aid in the prevention or the development of, pressure ulcers. The charge nurse, on each shift, is responsible to assess, document and initiate the treatment based on the wound protocol, any changes in the skin integrity of each resident. He/she will document in the medical records in accordance with the facility's documentation policy. An incident report will be completed 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.