Roosevelt Rehabilitation And Healthcare Center

Based on review of facility policies and procedures, review of clinical records, and staff interview, it was determined that the facility failed to implement ordered treatment and services related to incontinence management for two out of 35 residents reviewed (Resident R125, R223).Findings Include:Review of clinical literature indicates that a catheter is a flexible medical tube inserted into the body to drain or deliver fluids, most commonly used to remove urine from the bladder when a person cannot void (urinate or empty the bladder) naturally. A Foley catheter and a suprapubic catheter are both types of urinary catheters but differ in placement and use: a Foley catheter is inserted through the urethra-the tube that carries urine from the bladder to the outside of the body-while a suprapubic catheter is surgically placed through the lower abdomen directly into the bladder, often for long-term use or when urethral catheterization is not appropriate; suprapubic catheters (SPCs) are generally preferred for long-term use, offering increased comfort, lower risk of urinary tract…

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 documentation, review of clinical records, observations, and staff and resident interviews it was determined that the facility failed to implement interventions consistent with resident assessed needs for one of two residents reviewed for nutrition (Resident R3).Findings Include:Review of Resident R3's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 20, 2026, revealed the resident was deemed cognitively intact, had diagnoses of muscle weakness and dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), and had an unhealed pressure ulcer (localized injury to the skin and/or underlying tissue).Continued review of Resident R3's comprehensive MDS dated [DATE], revealed the resident required setup or clean up assistance with eating, had an unplanned weight loss of 5% or more in the last month or weight loss 10% or more in the last six months, and 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.

Based on review of facility policy, review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to ensure medication regimen reviews were timely addressed by the physician for three of five residents reviewed (Resident R3 and R5).Findings Include:Review of facility policy Medication Regimen Reviews revealed medication regimen reviews (MRR) are conducted at least monthly by a licensed pharmacist. The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems, errors, and other irregularities.Review of Resident R3's Medication Regimen Review Recommendation to Prescriber dated December 22, 2025, revealed the following recommendation [Resident R3] currently receiving abilify (antipsychotic medication_. Abnormal involuntary motion scale (AIMS) test recommended every 6 months to assess for the development of side effects of neuroleptic medication. Last documented in May 2025. Due now, please consider ordering Further review of Resident R3's MRR dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for 1 of the three residents reviewed. (Resident R250).Findings include:Review of the facility policy titled Enhanced Barrier Precautions, December 2024, revealed that Enhanced Barrier Precautions (EBP) are utilized to prevent the spread of multidrug-resistant organisms (MDROs). Under bullet #2, Enhanced Barrier Precautions apply when a resident is infected or colonized with a CDC-targeted MDRO but does not have a wound or an indwelling medical device and does not have secretions or excretions that cannot be covered or contained; or when a resident not known to be infected or colonized with any MDRO has a wound or an indwelling medical device and does not have secretions or excretions that are unable to be covered or contained, and contact precautions do not otherwise apply. Under bullet #4, it further states that standard precautions apply to the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy, clinical record review and interview with staff and residents, it was determined that the facility did not maintain complete and accurate medical records for one of 12 records reviewed (R1)Findings Include: Review of clinical record revealed that resident R1 was admitted to the facility on [DATE], with diagnoses including, but not limited to, low back pain, end stage renal disease, chronic pancreatitis, and osteoarthritis. The resident died in the facility on [DATE].Review of physician orders for resident R1 revealed an order for OxyCODONE HCl Capsule 5 MG Give 1 capsule by mouth every 4 hours as needed for Pain. The order was active from [DATE], to [DATE], when it was discontinued following her death.A nursing note for resident R1 signed by employee E3, dated [DATE], at 3:09 a.m. stated s/s (signs and symptoms) of pain. x1 prn (as needed) med oxycodone given. [Positive] result. Review of the narcotic reconciliation log revealed that an oxycodone was signed out 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 interviews and record reviews, the facility failed to provide a resident environment free of accident hazards for one resident (Resident R1), resulting in Resident R1, who was diagnosed with dementia, accessing the facility's main kitchen unattended and unsupervised during nighttime/after-hours. One of five residents reviewed.Findings include:Review of the clinical record for Resident R1 revealed diagnoses that included dementia(a range of medical conditions characterized by a decline in memory, language, and thinking skills severe enough to reduce a person's ability to perform everyday activities) and anxiety.Review of the MDS (assessment of resident needs) dated August 22, 2025, revealed that the resident had a BIMS(Breif Interview for Mental Status) score of 3, which indicated that the cognitive status for Resident R1 was severely impaired.Review of the facility investigation dated August 27, 2025, revealed that staff responded to a fire alarm activated in the kitchen and found Resident R1 in the kitchen, seated in her wheelchair, stating she had been looking 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.

Based on the review of facility documentation, clinical records and interviews with resident and staff, it was determined that the facility failed to provide necessary pharmaceutical services for one of five residents reviewed. (Resident R2)Findings include: Interview with Resident R2 on January 26, 2026, at 11:00 a.m., stated she did not receive her medication muscle relaxant for the past two weeks, resident stated she was routinely taking it before sleeping to relive muscle spasm. Resident stated staff told her the medication was not available from the pharmacy. Interview with Employee E3 on January 26, 2026, at 12:00 p.m., confirmed that the medication was not available in the cart to give it to the resident. Review of physician orders for Resident R2 dated November 10, 2025, revealed medication orders for Cyclobenzaprine HCl Tablet 10 MG Give 1 tablet by mouth every 8 hours as needed for muscles spasms. Review of medication administration record (MAR) for Resident R2 for the month of December 2025 revealed that the resident received the medication, Cyclobenzaprine HCl Tablet, 15…

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 laboratory studies were promptly obtained as ordered by the physician for one of five clinical records reviewed (Resident R2).Findings include:Review of Resident R1's physician progress note dated September 6, 2025, indicated that resident was noted with elevated potassium level 5.5. and indicated that the blood likely hemolyzed (a condition where red blood cells (RBCs) burst, releasing their contents into the blood plasma or serum, which gives it a reddish tinge after centrifugation) and to repeat BMP (Basic Metabolic Panel) on September 8, 2025Review of Resident R1's physician progress note dated September 12, 2025, indicated that repeat BMP ordered for September 8, 2025, was not done and ordered for CMP (a blood test that measures multiple substances in the body to assess overall health and identify potential medical conditions).Continued review of clinical records for Resident R2 revealed no evidence that the lab ordered by the physician for September 8, 2025, 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 resident and staff interview, it was determined that the facility failed to furnish an appointment for outside services in a timely manner for one of 5 residents reviewed (Resident R2).During an interview on September 17, at 10:30 a.m. Resident R2 stated he needed to see an outside provider for wounds on the lower extremity which was following him in the community. Resident stated staff missed his appointment and did not arrange the transportation two weeks ago and on September 16, 2025. Resident stated staff told him prior to the appointment that the transportation was arranged. He stated at the time of the appointment he was told there was no transportation and the appointment was not completed.Resident R2's clinical record revealed an admission date of August 28, 2025, with diagnoses that included cellulitis (infection of skin) of right lower extremity and chronic venous hypertension ulcer of right lower extremity. Review of hospital record for Resident R2 on August 28, 2025, revealed that an appointment request to follow up with podiatry on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, staff interviews, resident interviews, and clinical record review, it was determined that the facility failed to provide showers to Resident R1 and feeding assistance to Resident R3. These were two of eight residents reviewed who were dependent on staff for activities of daily living. (Resident R1, R3).Findings include:A review of the Activities of Daily Living (ADL) Supporting Policy, last revised in April 2025, revealed: Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.Review of Resident R3's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of adult failure to thrive, dementia (irreversible degenerative disease of the brain), muscle weakness, abnormal…

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 policies, clinical record reviews and interviews with staff, it was determined that the facility failed to develop comprehensive person-centered care plans related to a urinary catheter care for one of 9 residents reviewed (Resident R1).Findings include:Review of facility policy, Care Plans, Comprehensive Person-Centered March 2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Review of Resident R1's clinical record revealed an admission date of August 12, 2024, with diagnoses including chronic kidney disease, urinary tract infection, prostatic hyperplasia with lower urinary tract symptoms, urinary urgency, and urinary retention.A progress note, dated August 8, 2025, stated: Day 1/3 (day of one of three) new Foley catheter 16Fr/10mL placed at urology appointment this morning.A review of the comprehensive care plan dated May 20, 2025, did not reveal a care plan for catheter care.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 upon review of clinical records, interviews with staff and residents and reviews of policies and procedures, it was determined the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, by failing to follow physician's orders for urinary catheter care for 1 of 3 residents reviewed and for the need of 1:1 staff supervision at all times for one of 9 resident reviewed. (Resident R1).Findings include:A review of the policy titled Cather Care, Urinary Policy, last revised dated August 2022 revealed The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Under documentation stated The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving care to catheters. 4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor.…

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 resident group interview, observations, and interviews with staff, it was determined that the facility failed to display proper contact information for the State Survey Agency, including the Hotline number on three of three nursing floors and lobby area. (Second, Third, Fouth Floor and lobby) Findings include: A Resident Council interview was held on April 24, 2025, at 1:30 p.m. with nine alert and oriented residents who regularly attend resident council meetings. When asked if they knew how to contact the Pennsylvania Department of Health (DOH) with a complaint, all residents said no. When asked again if anyone knew how to contact DOH, they all shook their head no, and Resident R103 said that he never saw this number posted, and that they should hand out pamphlets to everyone. Observations in the lobby area and on all three of the nursing floors (Second, Third and Fouth) on April 23, 2025, at 2:30 p.m. with the Administrator revealed that the State Department of Health contact information was not posted in the lobby or on any of the three nursing floors as required.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility policies and documentation and interviews with staff, it was determined that the facility failed to ensure the pharmacist recommendations were reviewed by the physician in a timely manner for three of five residents reviewed related to medication regime reviews (Resident R78, Resident 93 and Resident R114). Findings include: Review of facility policy, Medication Regimen Reviews revised May 2029 revealed the consultant pharmacist reviews the medication regimen of each resident monthly with the goal is to minimize adverse consequences of potential risk of medications. An irregularity refers to the medication that is inconsistent with acceptable pharmaceutical services standard of practice, the drug may not be supported by medical evidence, or without adequate monitoring, and or excessive doses that can be a risk to persons life, health or safety. The consultant pharmacist will then contact the physician, to report the irregularity. The physician then documents…

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 and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature for 6 of 6 residents interviewed (Residents R113 R195, R279, R103, R189 and R12). Findings include: Interview with Resident R12 conducted during the tour of the first floor unit on April 21, 2024 at 01:31 PM complained that food was cold and that she does not always get the meal items that she requested for. Interview with Resident R113, on April 21, 2025, at 11:41 a.m. revealed that the food is cold, especially the pancakes, ant that they never have cold cereal available. Interview with Resident R195, on April 21, 2025, at 11:45 a.m. revealed that the food the food sucks and is always cold. Interview with Resident R279, on April 21, 2025, at 11:49 a.m. revealed that the meals are messed up, the eggs are dry, that she doesn't like coffee, that they send a tea bag, but no hot water, and they don't send enough sugar for my hot tea and the cereal, and the food is always…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to appropriate cleaning techniques for medical equipment, on four of the seven Medication Administration Reviews (Residents R20, R176, R195, R227), and the Enhanced Barrier Precautions for four of seven residents treatments reviewed (R97, R168, R176, R195). Findings include: Review of facility policy titled Infection Prevention and Control Program revised June 2022, revealed the facility has an infection prevention and control program which monitors development and transmission of communicable disease and infections to promote safe sanitary and comfortable environment for residents' staff and visitors. Policies of this program include standard of transmission-based precautions and how and when isolation should be used for a resident including type and duration of isolation hand hygiene procedures. Review of facility policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to monitor the urine output one of one resident review with a urinary indwelling catheter. (Resident R49) Findings include: Review of Resident R49's clinical record revealed that Resident R49 was admitted to the facility on [DATE], with diagnoses of but not limited to Multiple Sclerosis (slow progressive disease of the central nervous system), Spastic Hemiplegia (weakness on one side of the body), and Presence of Urogenital Implants, Review of Resident R49's physician's orders revealed the following order: Urinary Catheter # 16 Fr/30ml balloon inflation to urinary Drainage Bag. Observation conducted on April 21, 2025, at 10:25 a.m. revealed that Resident R49 had a urine bag hanging under her bed with tubing connecting the bag to the resident. Further observation revealed that the urine bag and the tubing contained 50 cc of very cloudy liquid with sediments settling at the bottom of the urine tubing and urine bag.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and staff interviews, it was determined that the facility failed to implement interventions to maintain acceptable parameters of nutrition for one of 8 residents reviewed for nutrition. (Residents R38) Findings include: Review of facility policy titled, Supplementation dated January 2025, revealed that resident may benefit from a therapeutic supplement if they present with unplanned weight loss; impaired skin integrity; and reduction in the amount of food or drink is consumed by mouth. Review of Resident R38's clinical record revealed that the resident was admitted to the facility was on February 25, 2025, with diagnoses including malnutrition (lack of sufficient nutrients in the body), metabolic encephalopathy (brain dysfunction), muscle weakness, and cachexia (ill health involving weight and muscle loss). Further review revealed a BIMS score of three, indicating severe cognitive impairment. Review of Resident R38's nutrition assessment dated [DATE], revealed that the 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 observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of six residents reviewed (R125). Findings include: Review of the Facility Policy and Guidelines for Implementation of Oxygen Administration indicated that the nurse should review and follow the physician's orders while administering Oxygen via nasal canula. Review of Resident R125's clinical record revealed; the resident was initially admitted to the facility on [DATE]. Resident R125 was diagnosed with Chronic Obstructive Pulmonary Disease (Chronic Obstructive Pulmonary Disease -COPD- is a progressive lung disease characterized by airflow obstruction, primarily caused by long-term exposure to irritants like cigarette smoke), and Acute Respiratory Failure (Acute respiratory failure is a life-threatening condition where the lungs cannot adequately provide oxygen to the blood or remove carbon dioxide). Review of clinical…

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 the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for two of four dialysis residents reviewed (Residents R66, R125). Findings include: Review of Resident 66's physician order, dated March 6, 2025, revealed Resident R66 received dialysis treatment on Tuesdays, Thursdays, and Saturdays. Review of Resident R66 's Hemodialysis Communication Record revealed that it was lacking the following information as required per the communication log: On March 6, 2025, March 13, 2025, March 15, 2025, March,20, 2025, March 20, 2025, March 25, 2025, April 3, 2025, April 8, 2025, the information for new orders received and sent with patient, comment; shunt site observation; ports capped and completed yes or no, patient reports pain yes or no, lab values; pertinent /relevant observations; Signature/Title of staff, andTime. Interview with the Licensed Nurse, Employee E22, on April 24, 2025, at 10:09 a.m., confirmed lack of information in the Hemodialysis Communication 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility did not ensure the timely acquiring of medications from pharmacy for a newly admitted resident for one of one of 35 residents reviewed . (Resident R277). Findings Include: Review of the Policy, Administering Medications, Revised April 2019, states Medications are administered in a safe and timely manner, and as prescribed. Interview with Resident R277 on April 21, 2025, at 11:00 a.m. revealed that he did not get his prescribed cardiac medications on the day of his admission on [DATE]. Resident R277's wife confirmed this stating that she was very upset that they did not have his heart medications available. Review of the medical record revealed that Resident R277 was admitted on [DATE], with diagnosis including, but not limited to acute congestive heart failure (a sudden, life-threatening condition in which your heart is unable to do its job. Your heart is still beating, but it can't deliver enough oxygen to meet your body's…

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

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for three of seven residents observed during medication administration (Residents R17, R20, and R195). Findings include: On April 22, 2025, at 9:29 a.m., observed that Employee E21, a Licensed Nurse, administered to Resident R20, the medicine, Breo Ellipta Aerosol Powder Breath Activated 200-25 MCG/INH (Fluticasone Furoate-Vilanterol), one puff inhale orally, and it was noticed that R20 did not rinse his mouth after inhaling Breo Ellipta Aerosol Powder. Review of physician order for Resident R20, revealed an order, dated June 29, 2022, to administer Breo Ellipta Aerosol Powder Breath Activated 200-25 MCG/INH (Fluticasone Furoate-Vilanterol), one puff, inhale orally one time a day for COPD, Rinse mouth and spit after administration. The Licensed Nurse, Employee E21, did not follow the physician order as the Resident R20 inhaled Breo Ellipta Aerosol Powder Breath Activated 200-25…

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 resident and staff interviews, it was determined that the facility failed to honor resident food and drink preferences by providing food that was requested by and acceptable to the residents for six of 35 residents reviewed (Residents R279, R103, R189, R31, R53 and R27). Findings include: Interview during the initial tour of the 2 North unit with Resident R279 on April 21, 2025, at 11:35 a.m. revealed that she does not get the right food, not what I choose on my menu, that this happens several times a week. During a group interview on April 23, 2025, at 1:30 p.m. when food was brought up and all residents agreed that there were problems in the kitchen. Resident R103 stated that you don't always get what you want. Resident R189 stated that she does not always get what she wants either. Resident R31 stated that things are not always right on her meal tray, they forget things like my sugar. Interview with the Administrator on April 24, 2025, at 12:45 p.m. revealed that there had been problems in the kitchen and that they brought a management company in to run…

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

Based on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: Review of facility policy titled, Food Receiving and Storage dated 2001 indicated that refrigerated foods should be labeled, dated and monitored so they are used by their use by date, frozen, or discarded. A tour of the Food Service Department was conducted on April 21, 2025, at 9:37 a.m. with Employee E12, Food Service Director (FSD), revealed the following concerns: Observations revealed a foul smell, caused by food debris, in the dishwasher area. The walls contained streaks of black dirt. Observations in the walk-in cooler revealed the following items were dated with the received date only: 10-pound turkey received 4/16; beef bologna received 4/4; and two 10-pound ground beef received 4/18. Continued observations revealed top round with a received date of 4/16; interview with he FSD revealed that it was pulled from…

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 resident and staff, and review of facility provided documentation, it was determined facility failure to ensure that one of 12 residents receive the breakfast meal. ( Resident R3) Findings include: Review of facility's policy 'Assistance with meals,' revised on March 2022, indicates that nursing staff will remove food trays from the food cart and deliver the trays to each resident's room. Interview with Resident R3, revealed that on January 7, 2025 his assigned nurse aide, employee E3, refused to change his bed linens upon request. Further interview with Resident R3 revealed that on the following morning, January 8, 2025, he did not receive his breakfast tray - which he believes was part of retaliation from E3 after he reported her to unit manager, employee E4, for refusing to change his bed linens. According to further interview with Resident R3, Employee E3 was his assigned nurse aide on January 8, 2025. Interview with Unit manager, Employee E4, on January 24, 2025 at 1:00 pm, revealed that on the morning of January 8, 2025. Employee E3 was re-assigned 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, observations, and interviews with staff, it was determined that the facility failed to provide incontinence care in a timely manner for four of six residents reviewed. (Resident R1, R2, R3, R4) Findings include: Review of Resident's R1's clinical record revealed Resident R1 was admitted to the facility October 17, 2024 with a diagnosis of chronic Obstructive Pulmonary Disease (condition that prevents airflow to the lungs, causing breathing problems), Anemia (lack of healthy red blood cells to carry oxygen to the body's tissues), and Coronary Artery Disease (condition where the major blood vessels supplying the heart are narrowed, which reduces blood flow). Review of R1's Minimum Data Set (MDS), completed on November 11, 2023, revealed Brief Interview for Mental Status (BIMS) score of 14, which indicated that the resident's cognition is intact. Additional review of the MDS revealed that Resident R1 is dependent for toileting hygiene. Observation in Resident R1's room revealed Resident R1's call bell wrapped around the back of the resident's bed.…

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 policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was prepared and served under sanitary conditions, in accordance with professional standards for food service safety. Findings include: Facility's Policy titled Food Receiving and Storage last revised November 2022 revealed Foods shall be received and stored in a manner that complies with safe food handling practices. Under Dry Food Storage 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated (used by date). Under Refrigerated/Frozen Storage further states 1.All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by, frozen, or discarded: The facility's policy regarding food and nutrition services, dated August 14, 2023, indicated that employees will wear a clean and appropriate hairnet/hair restraint, and beards and facial hair will be contained. Observations conducted on June 30, 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 review of facility documents, resident interviews, meal tray observations and staff interviews, it was determined that the facility failed to provide palatable, attractive, and at a safe and appetizing temperature meals during lunch for two of two meal observations. ( June 30, 2024, and July 1, 2024). Findings include: Review of facility's policy titled Food Preparation and Service revised November 2023 revealed Danger Zone means temperatures above 41 degrees Fahrenheit (F) and below 135-degree F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. A test tray performed on the Fourth floor by the Regional Dietary Director, Employee E14 revealed that on June 30, 2024, the planned hot meal served was Glazed Pork Loin , Roasted Sweet Potatoes, Seasoned Fresh Cauliflower. Alternative meal was Stuffed Shells with Sauce and Steamed Cauliflower. Desert was yellow cake and a choice of beverage. On June 30, 2024, at 11:50 a.m. observations were conducted with the Regional Dietary Director, Employee E14 who confirmed that Resident R22 received 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 review of clinical records, observation, and interview with staff, it was determined that the facility failed to implement enhanced barrier precautions and practice infection control practice relating to residents dining for 4 of 36 residents reviewed. (Resident 52, Resident R146, Resident 101, Resident 194) Findings include: Review of the facility policy titled Enhanced Barrier Precautions dated August 2022. Revealed that enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. The Enhanced Barrier Precautions (EBPs) employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. The policy specifies that gloves and gown are applied prior to performing the high contact resident care activity (as opposed to Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs which include: dressing, bathing/showering; transferring; providing…

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 facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system that includes antibiotic use protocols and a system to effectively monitor antibiotic usage for six of six months of antibiotic stewardship program data reviewed. (January 2024, February 2024, March 2024, April 2024, May 2024 and June 2024). Findings Include: Review of facility policy Antibiotic Stewardship: Review and Surveillance of Antibiotic Use and Outcomes dated December 2016 , revealed the Antibiotic sage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. 1.As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist (IP), or designee. 2. The IP, or designee, will…

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 observations and interview with the staff, it was determined that the facility failed to ensure a clean and homelike environment two of three nursing units. (Third floor and Fourth Floor) Findings included: Observation of room [ROOM NUMBER] on June 30, 2024, at 9:41 a.m. revealed that there was water dripping from the ceiling. There was also a piece of ceiling tile missing. The dripping water was collected in a trash can, which was almost full. Interview with Resident R57 on June 30, 2024, at 9:41 a.m. stated the water had been leaking from ceiling for a few weeks now, it started when the facility turned on the air conditioner in May. Resident also stated facility staff was aware of the issue and did not fix the water leak. A follow up interview with Resident R57 on July 1, 2024, 11:00 a m. statedthat the facility staff replaced the tile with out fixing the water leak properly and the ceiling tile collapsed to the floor with water. Observation of Room for 423 on June 30, 2024, at 10:39 a.m. revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the minimum information necessary to properly care for a resident, for one of three residents reviewed related to respiratory care (Resident R266). Findings include: Review of facility policy, Care Plans - Baseline dated revised March 2022, revealed, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Interview on June 30, 2024, at 11:11 a.m. Resident R266 stated that nursing staff don't always offer to assist her with caring for her laryngectomy tube (tube placed after the surgical removal of the larynx or voice box) and that she cares for it herself. Observation, at the time of the interview, revealed that Resident R266 had a laryngectomy tube that appeared clean…

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 documents and policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop a comprehensive person-centered care plan related to smoking for one of three residents reviewed related to smoking (Resident R177). Findings include: Review of facility policy, Care Plans, Comprehensive Person-Centered dated revised March 2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Continued review revealed, Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. Review of facility policy, Smoking Policy - Residents dated revised October 2023, revealed, Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: current level of tobacco consumption; method…

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 observations, review of clinical records, and interview with staff and resident, it was determined that the facility failed to ensure that a resident with limited range of motion, received appropriate services to prevent further decline in range of motion and maintain appropriate positioning for one of one resident reviewed for positioning and mobility. (Resident R72). Finding Include: Interview with Resident R72 on June 30, 2024, at 9:52 a.m. stated he had contractures to his hand. Resident stated the contracture was a result of stroke. Resident stated he was not provided any services in the facility including exercise or splinting to prevent worsening of the contracture. Observation of Resident 72 June 30, 2024, at 9:52 a.m. revealed that the resident was laying in the bed. It was observed that both resident's hands appeared to be contracted. The resident was not using any positioning devices or splints. Review of physician progress note dated June 18, 2024 revealed that the resident had hemiplegia (Muscle weakness or partial paralysis on one side of the body that can…

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

Based on the review of facility policy, clinical records and interview with staff, it was determined that the facility failed to provide acceptable nutritional parameters for one of 36 residents reviewed. (Resident R194) Findings Include: Review of facility policy Weight Policy dated December 2022, revealed that It is the policy of this facility to weigh each resident on admission, then weekly for (4) four weeks, then monthly thereafter, unless otherwise ordered by physician/IDT team. The facility will utilize a consistent procedure for monitoring weights and prevent unnecessary weight loss/gain in our residents. Any resident displaying a significant change in weight of greater than or equal to 5%. gain/loss in one month will be reported to the Registered Dietitian and reweighed. The Registered Dietitian will review the medical record of residents with significant weight changes (i.e. 5% loss/gain in one month, 7.5% loss/gain in 3 months, 10% loss/gain in 6 months). Dietary interventions will be recommended as needed. All significant weight changes will be reported to the MD…

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, review of facility policy and staff interview, it was determine that the facility failed to ensure ongoing records of communication between the facility and the dialysis center for one of three residents reviewed receiving dialysis. (Resident R58) Findings include: Review of the facility's policy titled Policy End Stage Renal Disease revised September 2010, revealed that residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Review of Resident R58's quarterly Minimum Data Set (MDS- assessment of resident's needs) dated February 16, 2024, revealed that the resident was admitted into the facility on April 30, 2020 with diagnosis's including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular coarse of long-term dialysis or a kidney…

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

Based on review of clinical record, review of facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of 7 residents reviewed for nutrition (Resident R194). Findings include: Review of facility policy Weight Policy dated December 2022, revealed that It is the policy of this facility to weigh each resident on admission, then weekly for (4) four weeks, then monthly thereafter, unless otherwise ordered by physician/IDT (interdiciplinary team). The facility will utilize a consistent procedure for monitoring weights and prevent unnecessary weight loss/gain in our residents. Any resident displaying a significant change in weight of greater than or equal to 5%. gain/loss in one month will be reported to the Registered Dietitian and reweighed. The Registered Dietitian will review the medical record of residents with significant weight changes (i.e. 5% loss/gain in one month, 7.5% loss/gain in 3 months, 10% loss/gain in 6 months). Dietary interventions will be recommended…

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, interview with staff, and review of facility policy, it was determined that the facility failed to ensure the physician documented the review of pharmacy recommendation and failed to document the rational for rejection of recommendation for one of three clinical records reviewed. (Resident R13) Findings include: Review of facility policy titled Medication Regimen Reviews revealed that the consultant pharmacist reviews the medication regimen of each resident at least monthly. The goal of the medication regimen review is to promote positive outcomes while minimizing adverse consequences and potential risks associated with the medication. An irregularity refers to the use if the medication that is inconsistent with accepted pharmaceutical standards of practice. The attending physician documents in the medical record that the irregularity has been reviewed and what action was taken to address it. Review of Resident R13's July 2024 physician orders revealed that Resident R13 has an order dated July 4, 2023, for Aripiprazole (Also known as Abilify, an…

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 interviews, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards of practice for four of six medication carts observed. (Second floor center, Third floor center, Third south, and Forth floor center). Finding include: Review of facility policy titled Medication Storage and Labeling revised February 2023 revealed that the nursing staff is responsible for maintain medication storage and preparation areas are clean, safe, and sanitary manner. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes at minimum medication name prescribed dose, strength,expiration date, residents name, route of administration, and appropriate instructions and precautions. For over-the-counter medications in bulk containers, the label contains medication name, strength, quantity,…

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

Based on observations, review of facility policy and staff interviews, it was determined that the facility failed to provide food products based on the resident's food preference for four of 36 residents (Resident R22, R23, R98, R155). Findings include: Review of facility policy Resident Food Preferences, last revised July 2017, indicates Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Upon resident's admission, the dietitian and/or nursing staff will identify a resident's food preferences. On June 30, 2024, at 11:50 a.m. observations were conducted with the Regional Dietary Director, Employee E14 who confirmed that Resident R 22's lunch preference ticket documented mechanical soft diet of ground pork loin, roasted sweet potatoes, seasoned fresh cauliflower and bread or roll with butter. Resident R22 lunch tray had mashed potatoes instead of sweet potatoes and no bread or roll with butter. Employee E14 confirmed that it should be mashed sweet potatoes and not mashed potato. On June 30, 2024, at 12:24 p.m. observations were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and interviews with residents, it was determined that the facility failed to maintain an effective pest control program in the resident care areas for two resident rooms units reviewed. (room [ROOM NUMBER] and room [ROOM NUMBER]) Findings include: Observation of Resident room [ROOM NUMBER] on June 30, 2024, at 9:41 a.m. revealed that there was a sticky fly trap hanging from the ceiling with dead flies on it. Interview with Resident R70 stated there was flies in the facility and he used the trap to catch the flies. He stated he was using the trap for a while. Interview with Resident R107 stated there was mice, rats, flies and roached in his room. Resident points to the floor where there were roaches behind the door and inside the bathroom. Observation of Resident room [ROOM NUMBER] on June 30, 2024, at 10:39 a.m. revealed that there were flies in the room. Roaches were observed behind the door and inside the bathroom. The above observations were confirmed by the Administrator on July 3,…

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

Based on review of facility policy and documents, staff interviews, and observation it was determined that the facility failed to provide training on infection control procedures relating to enhanced barrier precautions for seven of eight employees interviewed. Findings include: Review of the facility policy titled Enhanced Barrier Precautions dated August 2022. Revealed that enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. The Enhanced Barrier Precautions (EBPs) employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. The policy specifies that gloves and gown are applied prior to performing the high contact resident care activity (as opposed to Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs which include: dressing, bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; . device care or use (central line, urinary catheter,…

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, observations, and interview with staff, it was determined that facility failed to provide incontinence care in a timely manner for two residents out of 16 reviewed. (Resident R1 and R2) Findings include: Review of Resident's R1's clinical record revealed diagnosis of disorder of the skin and subcutaneous tissue, rash and other nonspecific skin eruption and resident R1 is care planned for check resident approximately every 2 hours and provide incontinence care as needed. Review of R1's minimum data set (MDS), completed on November 11, 2023, revealed Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident's cognition intact. Additional review of the MDS revealed that Resident R1 required 2 people assist for ADL's. Review of R2's minimum data set (MDS), completed on October 30, 2023, revealed Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident is cognitively intact. Additional review of the MDS revealed that Resident R1 required 2 people assist for ADL's. Interview with R1 on March 1,…

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 obtain physician orders related to weekly weights for one of 13 residents reviewed (Residents R1). Findings include: Review of the facility policy titled NutraCo weight policy revised December 2023, revealed It is the policy of this facility to weight each resident on admission, then for 4 weeks, then monthly thereafter, unless to otherwise ordered by physician/IDT team. The facility will utilize a consistent procedure for monitoring weights and prevent unnecessary weight loss/gain in our residents. Review of Resident R1's admission MDS, dated [DATE], revealed that the resident was admitted to the facility on [DATE], and had diagnoses of rhabdomyolysis (condition characterized by the breakdown of muscle tissue that leads to the release of muscle fiber contents into the bloodstream), acute kidney failure with medullary necrosis, pneumonitis due to inhalation of food and vomit.…

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 facility policy review, clinical record review and interview with staff, it was determined that the facility failed to ensure that a safe environment was provided for one of 10 residents reviewed. (Resident R7). Findings include: Review of facility policy titled Visitation Policy-Addendum Procedure, undated, revealed that Upon Entry to the facility, facility staff will issue all visitors a 'VISITOR' badge, and When a visitor is exiting the facility, front desk personnel will only open the front entrance door upon receipt of a 'VISITOR' badge. Review of clinical documentation revealed that Resident R7 was admitted to the facility on [DATE], with the diagnoses of dementia (a condition of decline in memory and decision-making abilities), alcohol abuse and encephalopathy (a disease in which the functioning of the brain is affected). Review of Resident R7's elopment assessment at the time of admission revealed that the resident was assessed at elopement risk. A wanderguard bracelet (a device that alarms when…

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

Based on observations of the physical environment of the kitchen and basement of the facility, reviews of the pest control operators reports and interviews with staff and residents, it was determined that the facility was not maintaining an effective pest control program throughout the building. Findings include: Observations of the loading dock and receiving area of the facility; which was located in the basement revealed that the double doors leading out of the building did not seal properly upon closing. An inch gap was noted at the treshold of the doors. This gap allowed easy access inside the facility for common household pests and rodents. Observations of the trash and garbage storage area; which was located along side of the loading and receiving area in the basement of the facility revealed that a barrel of rancid (smelling or tasting unpleasant as a result of being old and stale) and previously used cooking oil that was awaiting removal from the premises. The barrel was overflowing with thickened oil and fat; that had been used during the cooking process in the main…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that pain assessments were documented for one of six clinical records reviewed. (Resident R1). Findings include: Review of the clinical record for Resident R1 revealed that the resident was admitted to the facility on [DATE], for short-term rehabilitation following discharge from a hospital for treatment of a fracture of the right lower leg. Review of Resident R1's August 2023 physician orders revealed that an order was obtained for pain assessment to be conducted every shift. Review of Resident R1's Medication Administration Record revealed no documented evidence that a pain assessment was conducted on the following dates: August 23, 2023, August 28, 2023, and August 30, 2023. 28 Pa. Code 211.5(f) Medical records 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 observations, resident and staff interviews, facility policy, and the review of the clinical records, it was determined that the facility did not provide reasonable accommodations of needs related to toileting for two of 12 resident records reviewed. (Resident R2, R12) Findings include: Review of undated facility policy titled, Accommodation of Needs revealed that the residents individual needs, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. To accommodate individual needs, adaptations may be made to the physical environment, including the resident's bedroom, bathroom, as well as the common areas in the facility. The environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. Review of Resident R2's admission Minimum Data Set (MDS-an assessment of resident's needs) dated August 31, 2022, revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy and interviews with staff, it was determined that the facility failed to maintain a safe, clean home like environment for one of 12 residents observed. (Resident R3) Findings include: Review of facility policy titled, Smoking Policy- Residents revised August 2022, and interview with facility Administrator, Employee E1, on August 9, 2023, at 10:35 a.m., revealed residents are not permitted to smoke in resident rooms and bathrooms; Smoking and electronic cigarette use is only permitted in designated resident smoking areas, which are located outside of the building. Smoking is not allowed inside the facility under any circumstances. Observations on August 9, 2023, at 10:27 p.m. of room [ROOM NUMBER] revealed a lingering smell of cigarette smoke. Further observation of the resident bathroom in room [ROOM NUMBER] revealed fresh smell of cigarette smoke. Review of current facility list of smokers revealed that one (Resident R3) of two residents, (Residents R3, R11) who…

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.