St Monica Center For Rehabilitation & Healthcare

Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employees E7). Findings include: An interview on July 21, 2025, at 9:45 a.m. with Employee E7, Food Service Director (FSD), revealed that his responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Further interview with the FSD confirmed that he was not currently a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; and that he had not received frequently scheduled consultations from a qualified dietitian. A review of Employee E3's credentials revealed that Employee E7 did not meet the statutory qualifications of a director of food and nutrition services. During an interview on July 24, 2025, at 11:15 a.m. with Employee E1, Administrator, the FSD's personnel file and his qualifications were discussed which revealed he had been working at the facility…

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, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for five of 35 residents reviewed (Residents R18, R22, R60, R104, and R187). Findings include: A review of the undated Room Test Tray Evaluation form from Nutrition Services, Inc., revealed that the Standard for cold food is 40-55 degrees and for hot food 135-160 degrees.Interview with Resident R60 on July 21, 2025, at 10:30 a.m. revealed that he did not like that the hot food was often cold and the milk could be colder.Interview with Resident R187 on July 21, 2025, at 10:35 a.m. revealed that he is at the end of the hallway and his food is always cold, and that the French fries the other day were not even cooked, and that the eggs are terrible when they are cold. Interviews were held on July 23, 2024 with 12 alert, and oriented residents during resident council. Residents had complaints about the food served at the facility. Resident R18 stated, the food is cold,…

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 documents and interviews with staff, it was determined that the facility failed to ensure that terms of a binding arbitration agreement included required language to protect the rights of the resident or resident representative.Findings include: Review of Binding Arbitration Agreement, enclosed in the admission Agreement revealed that the agreement did not contain language that would allow the resident or anyone else (e.g., resident's representative) to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman.Interview on July 24, 2025, at 11:45 a.m. with Employee E1, Nursing Home Administrator and Employee E8, Regional Operations Director confirmed that the arbitration agreement did not contain the required language as state above.28 Pa. Code: 201.14(a)(b) Responsibility of licensee.28 Pa. Code: 201.18(b)(3) Management

Based on staff interview, review of hospice documentation and review of clinical records, it was determined that the facility failed to ensure that a recommendation from the contracted hospice agency related to a resident's medication management was addressed and/or implemented for 1 out of 1 hospice record reviewed (Resident R90). Findings include: Review of the facility policy, Hospice Program dated 3/25, indicated that when a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status.Review of Resident R90's July 2025 physician orders included the following diagnosis: multiple sclerosis (a disease that causes breakdown of the protective covering of nerves and can cause numbness, weakness, trouble walking, vision changes and other symptoms), chronic obstructive pulmonary disease (COPD- a term for lung and airway…

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

Based on observations and staff interview, it was determined that the facility failed to dispose of garbage and refuse properly where food and laundry is received. Findings Include: On September 27, 2024, 11:27 a.m., reviewed the dumpster area in the presence of the Director of Environmental Services, Employee E16 (dumpster is a large trash receptacle designed to be hoisted and emptied into a truck). The dumpster was leaking and oozing creamy colored, foul odorous liquid, through the sides of the dumpster, over the floor, around the dumpster, where the floor was irregularly covered with dark greasy appeared substances. At the time of the finding, E16 confirmed the observation. 28 Pa. Code 201.18(b)(3) Management

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 ensure two residents were free from significant medication errors for two of three residents reviewed. (Resident R24, and Resident R101) Findings include: Review of resident R 24's annual [NAME] Datra Set (MDS- a federal mandated process for clinical assessments for all residents) dated August 4, 2024, revealed that Resident R24 was readmitted to the facility on [DATE], with diagnoses of seizure disorder and dementia. Resident R 4 was assessed as having a BIMS (Brief Interview of Mental States) score of 5 indicating severely impaired cognition. Review of Resident R24's care plan revealed that Resident R 24 had seizure disorder with a plan to give medications as ordered, monitor and document for effectiveness and side effects. Review of Resident R24's physician orders revealed that Resident 24 had an order for Vimpat (Lacosamide, medication used to treat seizures) oral solution 10 milligram per mill give 15ML…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to address the potential for developing a pressure ulcer and develop/implement a plan of care to prevent pressure ulcers for one of 34 residents reviewed (Resident R145). Findings Include: Review of undated facility policy Care Planning Protocol revealed nursing provides an overview of medical and nurse care regimes. Nursing provides input especially related to activities of daily living, skin, weights, and safety needs. Care Are Assessment Summary triggers are reviewed by the team to decide whether to proceed with care planning for each triggered area. Review of Resident R145's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 25, 2024, revealed the resident was admitted to the facility on [DATE], was cognitively intact, and had a diagnoses of muscle weakness and malnutrition (an imbalance between the nutrients your body needs…

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 facility policy, observation, and staff interviews, it was determined the facility failed to ensure the resident's environment remained free of accidents and hazards relating to medication found at bedside for one of seven residents observed. (Resident R 153) Findings include: Review of facility policy titled Medication Administration Policy revealed licensed nursing professionals will administer medications according to time of administration determined by the facility. Medications administered outside the prescribed time frame requires physician notification and documentation in a medical record. Review of facility policy titled titled Self-Medication Administration Policy revealed that this policy applies to all residents who have been assessed and deemed capable of safely managing their own medications, in accordance with state regulations and nursing home protocols. Documentation of resident's eligibility, training, and ongoing monitoring will be maintained in the resident's medical records. Review of resident physician orders revealed no order or indication that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, observations, interviews with staff and residents, it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for one out of three sampled residents receiving hemodialysis (Resident 141). Findings include: A review of the clinical record revealed that Resident R141 was admitted to the facility on [DATE], with a diagnosis of Dependance on Renal Dialysis. Review of physician order for Resident R141, dated September 25, 2024, indicated a modification of the previous orders for Dialysis as follows: Resident receives dialysis on Tuesday/Thursday/Saturday, one time a day. (Dialysis is a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). Physician order dated September 19, 2024, for Resident R141, indicated to check Permacath at right chest wall, and to ensure caps are secure and that clamps are closed, Emergency Clamp at bedside. (A Permacath is a special catheter used for…

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

Based on review of facility documentation, review of clinical records, and staff interview. it was determined that the facility failed to develop and implement procedures that assure the accurate acquiring, receiving, dispensing, and administering of medications to meet resident needs for one of 34 residents reviewed (Resident R117). Findings Include: Review of Resident R117's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 22, 2024, revealed the resident was cognitively impaired and had a diagnosis of anxiety (a feeling of worry, nervousness, or unease). Review of Resident R117's comprehensive care plan dated October 5, 2022, revealed the resident used anti-anxiety medications related to anxiety disorder. Intervention dated December 8, 2020, included to give anti-anxiety medications as ordered. Review of Resident R117's physician order summary revealed a physician order dated June 17, 2024, to administer two milligrams (mg) of diazepam two times per day for anxiety. Review of Resident R117's medication administration record…

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

Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to ensure the attending physician timely reviewed identified irregularities and failed to document the action taken to address the irregularities for two of five residents reviewed (Resident 117 and 144). Findings Include: Review of undated facility policy Consultant Pharmacist revealed the consultant pharmacist will establish a system whereby the consultant pharmacist's observations and recommendations regarding the resident's drug therapy are communicated to the appropriate designee to implement and/or respond to the recommendations in an appropriate and timely fashion. Further review of facility policy revealed the timing of these recommendations should enable a response prior to the next drug regimen review. Review of Resident R117's Consultant Pharmacist Review Physician Report dated February 9, 2024, by consultant pharmacist, Employee E10, revealed the resident's medication olanzapine with Major Depressive Disorder (MDD) diagnosis will trigger for…

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

Based on review of facility documentation and clinical record review it was determined that the facility failed to ensure documentation for the need for a medication to treat a specific diagnosed condition with use of a psychotropic medication for one of five residents reviewed (Resident R117). Findings Include: Review of Resident R117's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 4, 2024, revealed the resident was cognitively impaired and had diagnoses of anxiety and depression. During the monthly medication regimen review, the pharmacist evaluates resident-related information for dose, duration, continued need, and the emergence of adverse consequences for all medications. Review of Resident R117's monthly medication regimen review, dated February 9, 2024, revealed recommendations by the Consultant Pharmacist, Employee E10, that olanzapine (also known as Zyprexa - antipsychotic medication used to treat severe agitation associated with certain mental/mood conditions) with major depressive disorder (MDD) diagnosis 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.

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 two of six residents observed during medication administration (Resident R29, and R151). Findings include: On September 26, 2024, at 9:39 a.m., observed that Employee E13, a Licensed Nurse, administered to Resident R 29, Vitamin D3 10 MCG 400 IU tablet. Review of physician order for Resident R29, revealed an order to administer Vitamin D3 Tablet 25 MCG (1000 UT) (Cholecalciferol), one tablet by mouth in the morning. At the time of the observation, interview with Licensed Nurse, E13, confirmed the above findings. On September 26, 2024, at 9:54 a.m., observed that Employee E14, a Licensed Nurse, administered to Resident R151, the medicine, Metoprolol Succinate ER (Extended Release) Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate), one tablet by mouth. Employee E14 was going to crush the Extended-Release Tablet, but was timely prevented from crushing the…

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

Based on review of facility documentation, review of clinical records, and staff interview, it was determined that the facility failed to obtain laboratory services to meet resident needs for one of 34 residents reviewed (Resident R10). Findings Include: Review of Resident R10's significant change Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 2, 2024, revealed the resident had a diagnosis of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior). Review of Resident R10's comprehensive care plan dated July 18, 2024, revealed the resident had potential for episodes of anxiety (a feeling of worry, nervousness, or unease) related to disease process, schizophrenia. Intervention included psychological consultation and treatment as needed. Review of Resident R10's physician order history revealed an order dated April 2, 2024, for Divalproex (also known as Depakote - a medication that contains valproic acid, used to treat manic episodes associated with mood disorder) 500…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records and interview with staff and residents, it was determined the facility failed to provide dental services in a timely manner for one of eight residents reviewed.(resident R 97) Finding include: Review of facility policy titled Dental Services revealed that the facility will assist residents in obtaining routine care, 24-hour emergency dental care and denture replacement in the case of loss, damage, or ill-fitting dentures. This dental care may be provided in-facility or by scheduling and transporting to a dental provider. In case of an emergency the resident will be transported to a facility that provides emergency dental services. Further review of this policy indicates that any resident identified needing dental services will be referred to the dental provider within 3 days of the identification, and the resident care plan and [NAME] will be updated as needed. Interview with Resident R97's family member on September 24, 2024, at 12:20 p.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.

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 hand hygiene, appropriate cleaning techniques for medical equipment, for four of the six residents observed during medication administration pass. (Resident 8, Resident 24, Resident 46 and Resident 155) Findings include: Review of Facility policy on Hand Hygiene, and Enhanced Barrier Precautions (EBP), effective date April 1, 2024, indicated that the staff will follow established infection control procedures such as hand washing, antiseptic technique, gloves, and isolation precautions for administration of medications, as applicable. It also indicated that all reusable equipment will be decontaminated and/or sterilized between residents at the point-of-care. On September 25, 2024, 9:24 a.m., during medication administration, to Resident R 155, Employee E15, a Licensed Nurse, used the sphygmomanometer (an instrument for measuring blood pressure), and the pulse oximeter (an electronic device…

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 policies and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation of one incident of resident injury sustained during a resident incontinence care for one of 34 residents reviewed . (Resident R67). Findings include: Review of the facility's policy titled, Residents/Patient Rights-Abuse, Neglect, Mistreatment or Misappropriation of Resident/Patent's Property not dated reveals, procedure are in place to prevent any incidence of abuse; neglect, mistreatment or misappropriation of resident/patient's property. Review of Resident R67's clinical record revealed that the resident was admitted to the facility on [DATE], with a diagnosis of cerebral infarction, occlusion, and stenosis of left middle cerebral artery hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, nontraumatic subarachnoid hemorrhage, aphasia, heart failure. Review of the Resident R67's quarterly Minimum Data…

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 a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for three of 34 sampled residents. (Residents 107, R86, R121). Findings include: A review of the facility policy titled Interdisciplinary Care Planning Protocol undated revealed Nursing admission Assessment completed on day of admission but in no event later than 24 hours of admission. Nursing initiates interim Care Plan - the interim care plan must address all immediate care needs. Review of Resident R107's clinical record revealed the resident was admitted on [DATE], with the diagnoses of chronic respiratory failure with hypoxia, chronic pulmonary edema, heart failure. Observation conducted on December 5, 2023, at 11:10 a.m. revealed resident having a oxygen concentrator near bedside and a portable oxygen tank behind his wheelchair. Oxygen was turned off during the interview. When questioned 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 observations, reviews of resident clinical records, facility policies and procedures, and interviews with staff and residents, it was determined that the facility failed to follow physician orders for one resident (R46) out of eight residents' medication administration reviewed and failed to follow physician orders for one of 34 sampled residents reviewed (Resdient R85). Findings include: Review of the clinical records of Resident R46 revealed; the resident was admitted to the facility on [DATE], with diagnosis including Chronic Obstructive Pulmonary Disease (COPD) (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems), and Hyperlipidemia (a condition in which there are high levels of fat particles-lipids- in the blood). Review of physician order dated April 26, 2023, for Resident R46, revealed an order for Aspirin Oral Tablet Chewable 81 MG, give one tablet by mouth, one time a day, to prevent stroke. On December 5, 2023, at 9:37 a.m., it was observed that 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 the review of clinical records, observations, and interviews with staff, it was determined that the facility failed to provide appropriate care and services for one resident needing continuous oxygen therapy for two of 34 resident records reviewed (Resident R2 and R107). Findings Include: Review of Resident R2's clinical record revealed the resident was admitted on [DATE], with the diagnoses of chronic respiratory failure with hypoxia, acute on chronic diastolic heart failure, peripheral vascular disease, dependence on supplement oxygen. Review of Resident R2 physician orders dated July 3, 2023, revealed 4 liters of oxygen was to be continuously administered via nasal cannula. Review of Resident R2's care plan dated January 4, 2023, revealed give oxygen therapy as ordered by the physician. Observation conducted on December 5, 2023, at 12:07 p.m. revealed that the oxygen concentrator was set at 3 Liter. This observation was confirmed by the license nurse, unit manager, Employee E14. Observation conducted…

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 interview with resident and staff, it was determined that the facility did not ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, and resident's goals and preferences for one of 34 residents reviewed (Resident R88) Findings include: Review of R88's clinical records revealed past medical history of presence of right artificial knee joint, fracture of surgical neck of left humerus, history of falls, depression, chronic pain, neurocognitive disorder with Lewy bodies. During interview with Resident R88 on December 4, 2023 at 11:45am, resident complained of being roughly handled during morning hygiene care. R88 stated the aide came in room asked if I needed to be changed, I said yes and she said to turn over on your side - when she turned she pulled my right leg backwards causing excruciating pain. I initially told woman to be careful with left arm because it was painful and it's in process of healing and is sensitive but she grabbed my left shoulder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of care and services, interviews with staff and residents and clinical record reviews, it was determined that the facility failed to assess each resident for the use of bed rails and obtain informed consent for the use of bed rails for one of three residents who had experienced falls. (Resident R86) Findings include: Observations of the bed used by Resident R86 at 10:30 a.m., on December 5, 2023 revealed that this resident had bed rails attached on either side near the head of the bed. Interview with the licensed nurse, Employee E9, at 9:30 a.m., on December 6, 2023 revealed that this nurse was familiar with the care of Resident R86. The nurse reported that there were no bedrail on the resident's bed at the time of the fall on September 8, 2023. The bed rails were added to Resident R86's bed post fall to assist with turning during incontinence care . Clinical record review for Resident R86 revealed a quarterly comprehensive assessment dated [DATE] indicating that this resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview with residents, residents' family members and staff, as well as review of facility's documentation, it was determined that facility did not ensure there are a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs and individual needs as required by the resident's diagnoses, medical condition, and plan of care for three of 34 residents reviewed. (Residents R69, R56) Findings include: Review of 'St. [NAME] Facility Assessment Tool' revealed Individual staff assignments are reviewed and determined daily by the charge nurse(s) with input from the interdisciplinary team based upon resident needs. Staff assignments are modified, as applicable, regarding resident care needs in order to provide optimal care for each resident. Interview with licensed nurse, employee E18, on December 4, 2023, at 11:18 am, on St. [NAME] unit, revealed that she was assigned to 30 residents and last thing I heard there…

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 develop and implement an individualized person-centered care plan to address residents' dementia care needs for one of 32 residents reviewed (Resident R143). Findings Include: A review of the clinical record of Resident R143, revealed; admission to the facility on July 6, 2022, with diagnoses that included 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), and Anxiety Disorder (Severe, ongoing anxiety that interferes with daily activities). Review of the Minimum Data Set (MDS), which is a Resident Assessment and Care Screening Item Set, dated May 1, 2023, also indicated that, R143 had the diagnosis of Dementia. On December 4, 2023, at 12:31 p.m., review of R143's interdisciplinary plan of care revealed no care plan pertaining to dementia care. During an interview on December 4, 2023, at 12:35 p.m., the Unit Manager, a Licensed Practical Nurse, Employee…

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 resident council interview, staff interviews, review of facility policy and reviews of the established meal time schedule, it was determined that the facility failed to ensure a nourishing snack was provided when 14 hours are between a substantial evening meal and breakfast in two of two nursing units. (3rd floor and 2nd floor unit). Findings include: A review of facility policy titled Nutrition Services (between meal and bedtime), serving undated revealed Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. A review of the established meal schedule for the residents revealed that the supper meal was scheduled for 6:30 p.m. on St. [NAME] nursing unit. The breakfast meal the following morning was scheduled for 8:45 a.m., on the St. [NAME] nursing unit. The times indicated on the meal time schedule were over fourteen hours, until the breakfast meal the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with staff, it was determined that the facility failed to ensure that the garbage and refuse area was maintained in a manner to prevent common household pests from entering the building. Findings include: Observations at 1:00 p.m., on December 4, 2023 revealed two sets of doors leading directly outside the building and into the driveway where garbage and refuse was being stored. The driveway contained an uncovered dumpster unit and a trash compactor, broken furniture, plastic crates and wooden pallets. This area was also used as a loading and receiving area for outside vendors to bring goods and services into the facility. The outdoor garbage and refuse holding area was located on the first floor of the facility. The St. [NAME], St. [NAME] and St. [NAME] nursing units were also located on the first floor of the facility. Further observations of the two sets of doors opening to the outside, revealed that the doors were not sealing securely. It was noted that the threshold of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents and resident clinical record and staff and resident interviews it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement for one of one residents reviewed (Resident R169). Findings include: Review of admission record indicated Resident R169 was admitted to the facility on [DATE] with the following diagnosis Post laminectomy syndrome (condition which patient continues to feel pain after undergoing a correctional laminectomy or another form of back surgery), muscle weakness, post cholecystectomy syndrome (the presence of abdominal symptoms after a cholecystectomy), post thrombotic syndrome (also called post phlebitis syndrome and venous stress disorder). Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and staff interviews, it was determined that the facility failed to maintain a safe, sanitary and home like environment for residents in two of two nursing units. (St. [NAME] 1st Floor unit and St. [NAME] 2nd floor,) Findings include: On December 4, 2023, at approximately 10:30 a.m. an interview was conducted with Resident R138 who reported that housekeeping staff do not remove trash out of her room on daily bases. On December 4, 2023, at 1:34 p.m. Resident R107 observed wheeling out in his room [ROOM NUMBER] in the wheelchair with a large and full garbage bag and wanted to throw away his trash into the housekeeping large trash can which was standing in the hallway. During the interview it revealed that housekeeping staff do not daily empty the personal trash can and R107 will not let his trash overflow. R107 restroom also was observed dirty with brown substance on the floor, restroom trash had no trash bag and had brown substance in the trash, used and unsanitary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program related to flying insects on one of four nursing units reviewed (third floor) and in the main kitchen. Findings include: Observations on December 4, 2023, at 10:21 a.m., of St. [NAME], the third floor, revealed there were flying insects that resembled house flies in the room of Resident R117, room [ROOM NUMBER] B. Observations on December 6, 2023, at 12:09 p.m., of St. [NAME], the third floor, revealed there were flying insects that resembled house flies in the room of Resident R117, room [ROOM NUMBER] B. On December 5, 2023, at 1:11 p.m. observation were made in room [ROOM NUMBER]-A and flies were observed by Resident R23's bedside. On the top of Resident R23'sbedside dresser there was a white pest trap. When questioned why there was a pest trap on the top of the dresser, R23 stated pest control exterminator placed it there. Observation was confirmed by the…

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

Based on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide assistance with showers for three of five residents reviewed (Residents R1, R4 and R5). Findings include: Review of facility policy titled Activites of Daily Living (ADLs) dated July, 1, 2021 stated based on the comprehensive assessment of a resident/patient (herein after patient) and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's activities of daily living (ADL) activities are maintained or improved and do not diminish unless circumstances of the individual's clinical condition demonstrate that a change was unavoidable. During observation on October 5, 2023, at 10:48 a.m. Resident R1 stated that her shower days are Saturdays and Wednesdays. Yesterday October 4, 2023, was a Wednesday and she did not get a shower. No one offered her a shower and she prefer a shower. During a follow up interview at 11:18 a.m. on this same day Resident R1 reported the last time…

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, interviews with residents and staff, review of facility policy, and review of facility documentation, it was determined the facility failed to ensure that call bells were available and working for five of five units observed. (St. [NAME], St. [NAME], St. [NAME], St. [NAME] , and St. [NAME] De [NAME]). Findings Include: Review of facility policy Call Bell Policy and Procedure dated 2/20 stated Resident will have functioning call bells to alert staff of their needs. Interview with Resident R2 on September 11, 2023 at 10:15 a.m. revealed the resident's call bell has not been working. The resident stated that the call bell has not been working for a few days now. Resident R2 stated that a nurse came in and gave him a call bell this morning but that other people have had their bells for a few days now. The call bell was tested at 10:21 a.m. and the call bell did not light at the base of the wall in Resident R2's room. At 10:31 a.m. the light was checked outside of the resident's room 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.