St John Neumann Ctr For Rehab & Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review facility policies and staff interview, it was determined that the facility failed to maintain a clean and homelike environment in resident care areas and dining experience for one of five nursing units observed ([NAME] dementia Unit). Findings Include: Review of facility policy Housekeeping Safe and Sanitary Living Arrangements dated on June 1, 1996, revealed, St. [NAME] Nursing Home shall provide a safe and hygienic living arrangement for residents as designated by governmental agencies for licensure and certification purposes. In order to comply with this mandate, we require that employee within the Housekeeping Department clean resident rooms including bathrooms daily. On May 20, 2025, at 11:12 a.m. an observation was conducted on the nursing unit [NAME] in room [ROOM NUMBER] revealed Resident's R1, R2 and R3 bathroom was dirty. The toilet bowl had spot feces all over with urine smell, bathroom was not clean and had files in the bathroom when opening the door. On May 20, 2025, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with residents and staff, it was determined that the facility failed to maintain resident care equipment in safe, operating conditions for three of seven nursing units toured (300, 400, and 700 nursing unit). Findings include: Review of facility maintenance work orders for five of five nursing units in the facility dated from September 9, 2024 through January 22, 2024 revealed multiple ongoing and reoccurring requests for residents' bathroom sink malfunction. Work order 7713 clogged sink room [ROOM NUMBER] Work order 7714 clogged sink room [ROOM NUMBER] Work order 7735 clogged sink room [ROOM NUMBER] Work order 7793 clogged sink bathroom Work order 7823 clogged sink room [ROOM NUMBER] Work order 7838 clogged sink rooms [ROOM NUMBERS] Work order 7855 clogged sink room [ROOM NUMBER] Work order 7883 clogged sink room [ROOM NUMBER] Work order 7887 clogged sink room [ROOM NUMBER] Work order 7902 clogged sink room [ROOM NUMBER] Work order 7914 clogged sink room [ROOM NUMBER] Work…

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 interviews with staff, it was determined that the facility failed to ensure that a resident with a facility-initiated transfer to the hospital was necessary and document the basis for the transfer in the residence medical record for one of three residents reviewed related to transfers. Resident R 212 Finding include: Review of Resident R 212's admission MDS (minimum data set a mandatory resident assessment tool), entry tracking records dated November 22, 2024, revealed that the resident was admitted to the facility on [DATE]. Residence R 212's discharge assessment dated [DATE], revealed that the resident was discharged for reason of behaviors and a return is not anticipated. Review of Resident R 212's clinical record revealed that this resident was admitted to the facility with diagnosis's including unspecified mood disorder, dementia, kidney failure, personal history of transit ischemic attack (a temporary blockage of blood flow to the brain), history of falling, bipolar…

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, it was determined that the facility failed to ensure that a baseline care plan was developed for a one of 35 residents reviewed. (Resident R212. Findings include: Review of Resident R212's admission Minimum Data Set (MDS-a mandatory resident assessment tool), entry tracking dated November 22, 2024, revealed that the resident was admitted to the facility on [DATE]. Resident R212's discharge assessment dated [DATE], revealed that the resident was discharged for reason of behaviors and a return is not anticipated. Review of Resident R212's clinical record revealed that this resident was admitted to the facility with diagnosis's including unspecified mood disorder, dementia, kidney failure, personal history of transit ischemic attack (a temporary blockage of blood flow to the brain), history of falling, bipolar disorder (a disorder classified by episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder, and anxiety disorder. Review of facilities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of care and services, clinical record reviews and interviews with responsible family members and staff, it was determined that the facility failed to ensure that a consultation with an optometrist or ophthalmologist was obtained for one of 35 residents reviewed (Resident R201) Findings include: Interview with the responsible family member for Resident R201 at 11:00 a.m. on January 21, 2025, revealed that the family member visits the facility at lunch time daily. The family also reported that he had spoken to the nursing staff about having Resident 201's eyes examined by a professional optometrist or ophthalmologist (branch of medicine concerned with the treatment of disorders and diseases of the eyes). Observations of Resident R201 on January 21, 2025, revealed that this resident was sitting in the well illuminated dining area. The family member said that he thinks both eyes were impaired because Resident R201 can not follow objects with her eyes. The family member said that Resident R201…

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, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma informed care accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for one of seven residents sampled (Resident R 191) Findings include: A review of the clinical record revealed that Resident R191 was admitted to the facility on [DATE], with diagnoses to anxiety disorder, and post-traumatic stress disorder (PTSD) Further review of the clinical record for Resident R191 revealed that the resident PTSD diagnoses is unknown by facility. Resident R191's current care plan on December 19, 2024, revealed a care plan for PTSD. Further review of the care plan did not address resident's actual diagnoses/condition of PTSD, identifying the resident's past experiences and possible triggers that may cause re-traumatization. Interview with the Social worker, Employee E6, 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 clinical record review and staff interview, 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 35 residents reviewed (Resident R 88). Findings Include: Review of the admission sheet of Resident R88, revealed that Resident R88 was admitted to the facility on [DATE]. Review of the admission sheet of Resident R88 indicated that, on January 30, 2023, Resident R88 was diagnosed with 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 of Minimum Data Set assessment (MDS- an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated December 16, 2024, revealed that Resident R88 had active diagnoses of Non-Alzheimer's Dementia (a progressive form of Dementia that destroys memory and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interviews, it was determined that the facility failed to obtain and report laboratory results to meet resident needs for three of 35 residents reviewed (Resident R72, R204, and R169). Findings Include: Review of Resident R72's Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated October 21, 2024, revealed the resident had a diagnosis of hyperkalemia (elevated levels of potassium in the blood because the kidneys are unable to excrete the excess potassium - severe symptoms can include muscle weakness or affect the heart). Review of Resident R72's clinical record revealed a physician progress note dated November 28, 2024, by Physician, Employee E10, that indicated Resident R72 had a nephrology (medical specialty that focuses on the study of kidneys) consult on November 8, 2024, with recommendations to implement a low potassium diet and to recheck labs in two weeks. Review of Resident R72's clinical record revealed the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documentation and interviews with residents and staff, it was determined that the Nursing Home Administrator failed to effectively manage the facility related to air temperatures between 71 degrees Fahrenheit and 81 degrees Fahrenheit in resident rooms and common areas for 19 cognitively impaired residents. This failure to maintain comfortable and safe air temperatures for residents residing in rooms 310, 311, 312, 313, 314, 315, 316 and 317 resulted in an Immediate Jeopardy situation. Findings include: Review of the job description for the Nursing Home Administrator revealed that the Administrator was responsible for the direct day to day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to the residents at all times. The Administrator was responsible to plan, developed, organize, implement,…

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

Based on review of facility policy, review of clinical records, and staff interviews it was determined that the facility failed to review and revise behavior health care plan for one of nine residents reviewed (Resident R1). Findings Include: Review of facility policy Interdisciplinary Care Planning Protocol reviewed February 2023 revealed problems established by the team with the resident/family must be specific and individualized. Review of Resident R1's Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated October 13, 2024, revealed the resident was cognitively impaired and had diagnoses of dementia (a decline in cognitive function severe enough to interfere with daily life), anxiety disorder (excessive fear, worry, and nervousness that disrupt daily life), depression (persistent feeling of sadness and loss of interest), and manic depression (bipolar disorder - a serious mental illness characterized by extreme mood swings). Continued review of Resident R1's MDS revealed the resident received an antipsychotic medication on a routine basis. Review…

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 provided documentation and interview with staff, it was determined that facility failed to ensure that a thorough investigation was conducted related to a injury sustained by a resident for one of five residents reviewed (Resident R1) Findings include: Review of facility policy 'Incident/Occurrence Investigation Policy,' revised on November 2023, indicates all injuries of unknown origin will be investigated to make a determination if a resident is a victim of abuse or mistreatment, and Nursing Administration or Social Services will conduct their initial investigation and review all pertinent documentation related to the event . Review of Resident R1's clinical record revealed a medical history of dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, colostomy status, major depressive disorder, stroke without residual deficits, falling, alcohol abuse, anemia, bipolar disorder, thrombocytopenia, obstructive and reflux uropathy. Review of nursing progress note dated…

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

Based on review of facility policies, clinical record review and interviews with residents and staff, it was determined that the facility failed to provide written notice, including reason for the change, before a resident's room change for one of 11 residents reviewed (Resident R2). Findings Include: Review of facility policy titled, Room Change, revised November 27, 2023, revealed that the facility may change a resident's room when it is medically necessary or if the resident requires a different level of care. Review of clinical records for Resident R2 revealed a progress note which stated that the resident was notified that he will be changed to a semiprivate room and that the family member was also informed. Interview with the Administrator, Employee E1, and Director of Nursing, Employee E2, on April 15, 2024, at 12:54 p.m. confirmed that the resident had a room change related to a change in level of care. Further interview confirmed that the facility failed to provide a written notice to resident or residents representative, including reason for the change, before 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, review of facility policy and interview with facility staff, it was determined that the facility failed to provide care and services to enhance residents' dignity related to feeding residents, serving meals on disposable paperware and providing incontinent care for four of 36 Residents reviewed. (Residents R79, R4, R21, and R18). Findings include: A review of the facility policy and procedure, titled, Feeding Residents, revised November 2023, states that it is the facility's policy to sit next to or face resident while feeding to promote socialization and correct feeding techniques. Clinical record review for Resident R79 revealed that resident was admitted to the facility on [DATE]. Observations during the initial tour of the facility on March 5, 2024, at 10:45 a.m. in Resident R79's room revealed that resident was laying in her bed, and stated that she had to urinate. The Unit Manager, Employee E6, who was also in the room asked her to wait. Resident R79 then said, should I go in my…

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 documentation and interviews with residents and staff, it was determined that the facility failed to ensure that residents had access to grievance forms and access to the contact information of the grievance official on five out of five nursing units. (300-700 nursing units). Findings include: Observations on March 5, 2024, at 10:55 a.m. of the 700 rooms nursing units revealed that no grievance forms and box were available for residents to be able to anonymously file a grievance. In addition, there was no information made available to residents on how to contact the grievance officer. Interviewed Unit manger, Employee E15 revealed that forms were filed in the nursing station. Continued observations on March 5, 2024 at 11:00 a.m. other nursing units revealed that no grievance forms were available for residents to be able to anonymously file a grievance. In addition, there was no information made available to residents on how to contact the grievance officer. Interview on March 5, 2024 at 1:45 p.m. a.m. with the Director of Social Work, Employee E13,…

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, observations, and interview with staff, it was determined that the facility failed to ensure that the resident environment was free of accident hazards related to medication administration for two out of 36 residents reviewed (Resident R147 and Resident R69) , and failed to ensure that hazardous materials were not accessible to residents on one of five nursing units. (700 unit) Findings include: Observation conducted on March 8, 2024, at 11:08 a.m. in the 700 unit by the nursing station shower room revealed that there was used twin blade disposable razors in the trash, on the sink and on the floor. Interviewed conducted with the Unit manger, Register nurse, Employee E12, revealed, and confirmed that razors should not been left out or thrown out in the trash in the shower room. It must be discarded in the sharp container after being used. The Unit manger, Register nurse, Employee E12, took all of razors and discarded them in the sharp container. Interview conducted with the Director of Nursing, Employee E2 on March 8, 2024, at 11:44 a.m.…

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

Based on observation, review of clinical record, review of facility policy and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and services for 3 of 36 residents reviewed (Residents R29, R60, and 195). Findings include: Review of facility policy for Tracheostomy care revised March 2024, revealed Check orders for tracheostomy care. Assure an extra tracheostomy tube with inner cannula is always available for emergency replace resident bedside as ordered. Assure an Ambu bag is at resident bedside for emergency procedure as ordered. Review of Resident R60's clinical record revealed the resident was diagnosed with tracheostomy status (procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck). Review of Resident R60's physician's orders dated March 5, 2024, revealed the tracheostomy cuffed Shiley number 4. Observation of Resident R60 conducted on March 5, 2023, at 11:44 a.m. with Unit manager, Employee E15, revealed no extra tracheostomy tube with inner cannula size 4 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 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 two of two residents observed for medication administration. (Resident R127, and Resident R13) Findings include: On March 6, 2024, at 8:34 a.m., observed that Employee E32, a Licensed Nurse, administered to Resident R127, Aspirin Enteric Coated Tablet 81 MG, one tablet. Review of physician order for Resident R127, dated September 22, 2023, revealed an order to administer Aspirin Tablet Chewable 81 MG, give 1 tablet by mouth in the morning for Coronary Artery Disease (Coronary Artery Disease Damage or disease in the heart's major blood vessels; the usual cause is the buildup of plaque; this causes coronary arteries to narrow, limiting blood flow to the heart). Review of medical literature, in, https://newsnetwork.mayoclinic.org/discussion, revealed that with enteric-coated aspirin, research indicated that bloodstream absorption may be delayed and reduced, compared to regular…

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, observations, and interviews with staff, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions on three of five nursing units. (700 unit, 300 unit and All Saints unit) Findings include: Review of facility policy titled Policy St [NAME] Storage of Medications revealed that the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, sanitary, manner. Further review of this policy revealed that medications requiring refrigeration must be stored in a refrigerator looked in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be locked accordingly. Observation of medication cart 700 third cart on March 8, 2024, at 10:10 a.m., revealed 31 unidentified looses pills in the top drawer of…

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

Based on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food that was palatable and served at the proper temperature for nine of 36 residents reviewed (Residents R119, R75, R31, R182, R34, R81, R85, R10, R71). Findings include: Review of facility policy titled, Food Temperatures, dated February 1, 2021, revealed that temperatures of food will be monitored to ensure safety and that hot foods must stay above 135 degrees Fahrenheit and cold foods stay below 41 degrees Fahrenheit during the holding and serving process. During a group interview, held on March 7, 2024, at 10:30 a.m. with Residents R119, R75, R31, R182, R34, R81, R85, R10, R71, revealed that food is not appetizing and palatable. Observations during lunch tray line on March 8, 2024, from 12:15 p.m. to 1:00 p.m. revealed that the fruit cups, pudding, sandwiches, and salads were prepared in bulk and observed on a rack not being chilled prior to tray assembly. Observations during a test tray conducted with the Food Service Director (FSD),…

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

Based on observation, review of clinical records, and staff interviews, it was determined that the facility failed to provide a communication device to maintain optimal communication for one of 36 residents reviewed. (Residents R189) The findings include: Observations during the screening process, on March 5, 2024, at 1:32 p.m. revealed that Resident R189 had a language communication barrier. When the surveyor approached Resident R189's room, the resident was observed laying in bed. When the surveyor requested permission to enter the room, the resident appeared anxious and voiced Nurse aide, Employee E20's name repeatedly. Further observations revealed that Resident R189 got out of bed, and roamed the hallway, anxiously calling for Employee E20. Review of Resident R189's admission Minimum Data Set Assessment (MDS, an assessment tool selected at specific intervals to determine care needs) dated, January 17, 2023, revealed that in section A, the resident was coded, yes for does the resident need or want an interpreter to communicate with a doctor or health professional? Review of…

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

Based on review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to ensure the appropriate size of an indwelling urinary catheter was used for one of 36 residents reviewed (Resident R2). Findings include: Review of Physician order dated February 16, 2022, for Resident R2, indicated an order to change Foley Catheter 16fr/10cc, every one month, one time a day, starting on the 16th and ending on the 16th every month. On March 7, 2024, at 11:39 a.m., reviewed the Foley Catheter of R2, in the presence of a Licensed Nurse, Employee E33, and observed that R2 had Foley Catheter Size 18 FR, with the Balloon Size 30 cc. At the time of the finding, Licensed nurse, Employee E33 confirmed that Resident R2 had the incorrect catheter size. 28 Pa. Code 211.12(d)(1) Nursing services

Based on the review of facility policy, facility wound care tracking, hospital records, clinical records, national pressure ulcer guidelines and interview with facility staff, it was revealed that the facility failed to conduct a thorough skin assessment of a resident with pressure ulcers and documented history of skin impairment, consistent with professional standards of practice for one of three residents reviewed. (Resident R1) Findings Include: Review of National Pressure Injury Advisory Panel, Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guidelines, 2019, revealed that Assessment of Pressure Injuries and Monitoring of Healing: Conduct a comprehensive initial assessment of the individual with a pressure injury. Set treatment goals consistent with the value and goals of the individual, with input from the individual's informal caregivers, and develop a treatment plan that supports these values and goals. Assess the pressure injury initially and re-assess at least weekly to monitor progress toward healing. Select a uniform, consistent method for…

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

Based on the review of clinical records, facility policies, hospital records and interviews with staff and resident representative, it was determined that the facility failed to ensure that a podiatry (a branch of medicine devoted to the study, diagnosis, and treatment of disorders of the foot and ankle) wound care recommendations from hospital was administered as recommended for one of three residents reviewed. Findings Include: Review of hospital record for Resident R1 dated December 27, 2023, revealed that the resident had anterior ankle and lateral foot wounds, pressure ulcer (Injury to skin and underlying tissue resulting from prolonged pressure on the skin.) to the left heel, which was unstageable, right heel pressure ulcer which was a Stage 1 and a sacral pressure ulcer which was a deep tissue injury (DTI- a serious form of pressure injury). Review of hospital After Visit Summary included a wound care recommendation from podiatry to bilateral feet, anterior ankle, and lateral foot. Recommendation indicated to remove previous dressing and rinse with saline, gently pat dry.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of clinical records, facility policy, hospital records and interview with staff and resident representative, it was revealed that the facility failed to provide necessary treatment and services to promote healing of pressure ulcer consistent with professional standards of practice for one of three residents reviewed. (Resident R1) Findings Include: Review of hospital record for Resident R1 dated December 27, 2023, revealed that the resident had anterior ankle and lateral foot wounds, pressure ulcer (Injury to skin and underlying tissue resulting from prolonged pressure on the skin.) to the left heel, which was unstageable, right heel pressure ulcer which was a Stage 1 and a sacral pressure ulcer which was a deep tissue injury (DTI- a serious form of pressure injury). Review of hospital Discharge summary dated [DATE], revealed an order to apply zinc oxide 40% paste, apply two times a day to sacrum and scrotum. Review of admission assessment for Resident R1 dated December 27, 2023, 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.

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 nine residents reviewed. (Resident R6) Findings include: Review of facility policy titled, Care planning, revised on September 2015, indicated that immediately recognizable problems should be cere planned upon admission including UTI (acute infections still requiring treatment). Review of Resident R6's clinical record revealed a nurses note dated July 25, 2023, which indicated that Resident R6 was being treated for a urinary track infection (UTI). Further review of Resident R6's clinical record revealed a physician order dated, July 21, 2023, for Ciprofloxacin HCl Oral Tablet; Give1 tablet by mouth two times a day for UTI for 7 days. Further review of Resident R6's clinical record revealed no documented evidence a comprehensive care plan was developed regarding UTI treatment. Interview with the Assistant Director of Nursing, Employee E5, was conducted on October 26, 2023, at approximately 2:34 p.m.…

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

Based on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food that was palatable and served at the proper temperature for five of eleven residents reviewed (Residents R5, R1, R3, R2 and R6). Findings include: Interview with Resident R5 on October 26, 2023, at 10:57 a.m. revealed that his hot food arrived cold in the morning. Interview with Resident R1 on October 26, 2023, at 11:01 a.m. revealed that the hot food was sometimes cold. Interview with Resident R3 on October 26, 2023, at 11:05 a.m. revealed that hot foods are cold and ice cream is all melted. Interview with Resident R2 on October 26, 2023, at 11:20 a.m. revealed that food is often cold. Interview with Resident R6 on October 26, 2023, at 1:38 p.m. revealed that his lunch consisted of beef stroganoff today and it arrived cold. Resident stated that he refused to eat the cold beef stroganoff. Observations during a test tray conducted with Employee E3, Food Service Director (FSD), on October 26, 2023, at 1:32 p.m., revealed the beef…

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.