Wesley Enhanced Living Pennypack Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and the review of clinical records, it was determined that the facility failed to ensure that physician orders were followed and recommendations were addressed regarding obtaining labs to ensure appropriate care and services could be provided for 1 out of 2 residents reviewed (Resident R1). Findings include: Review of a physician's note dated January 14, 2025 at 9:41 p.m. indicated that the resident was admitted to the facility on [DATE] from a local hospital after being brought to the hospital by his wife after exhibiting signs of increased confusion at home. The resident was subsequently diagnosed with acute encephalopathy (damage or disease that affects the brain that lead to an altered mental status) and a urinary tract infection. The resident was transferred to the facility for rehabilitation services once discharged from the hospital. Review of the March 2024 physician orders for Resident R1 included the following diagnoses: morbid obesity; transient cerebral ischemic attack (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 staff interviews and review of clinical records, it was determined that the facility failed to ensure that a recommendation for a resident to be seeen by an endocrinologist was addressed for 1 out of 2 residents reviewed (Resident R1). Findings include: Review of multi-disciplinary notes indicated that the resident had a visit that the resident had with the facility endocrinologist (a physician who specializes in the treatment of diagnosis, such as diabetes) on January 27, 2025 at 1:06 p.m. Recommendations to the residents current treatment plan were made. Continued review of the clinical notes from the endocrinologist indicated that the endocrinologist would follow up with the resident in 2-4 weeks and that the facility could contact the endocrinologist sooner with any questions, concerns, or any changes in the resident's health care status related to diabetes. Will follow up in 2-4 weeks. Please email [name of office] sooner with any questions, concerns or changed in the pts's DM (Diabetes Melittus) control. Review of multidisciplinary notes from January 14, 2025 through…

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 food and nutrition services department and reviews of the pest control operator's reports it was determined that the facility failed to maintain an effective pest control program so that the building was free of pest. Findings include: Observations of the main kitchen revealed a set of double doors in hallway outside the kitchen. These doors opened directly onto the concrete dock. Additional observations revealed a large metal dumpster unit just below the concrete dock; where garbage and refuse was held for later disposal. The double doors did not seal completely upon closing; that was an air gap was evident along the threhold of the doors allowing easy access to the building for pests and rodents. Observations on the second floor B wing nursing unit kitchenette revealed a mouse running across the floor into a hole/void underneath the wooden cabinets. There was obvious water damage surrounding these wooden cabinets inside this kitchenette. A dish machine and sink were noted as part of the kitchenette equipment 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 observations, reviewof clinical record, review of facility documents and staff interviews, it was determined that the facility failed to revise the care plan for activities of daily leaving for one of 31 residents reviewed (Resident R32). Findings include: Review of Resident R32's clinical record revealed that the Resident R32 was admitted in the facility on January 16, 2024. Resident R32's diagnoses included, Muscle Weakness, Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and judgment), and abnormalities of gait and mobility. Review of physician order for Resident R32, dated March 13, 2024, indicated an order for Physio-Therapy evaluation and treatment as indicated. Review of the care plan for Resident R32, initiated on January 16, 2024, with a target date of September 8, 2024, indicated that Resident R32 would demonstrate an improvement in Activities of Daily living status through skilled therapy intervention. Review of Resident R32's current care plan revealed that the resident's care plan was not updated or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility documentation, review ofd facility policies and interviews with staff, it was determined that the facility failed to provide adequate supervision to prevent elopement of one out of 31 residents reviewed (Resident R80). Findings include: Review of facility policy, Elopement of a Resident effective dated December 12, 2016, revealed that it was the policy of the facility to put measures into place to prevent residents room eloping (leave without staff knowledge) from the facility. The policy defined elopement as the ability of a resident, who is not capable of self-preservation to successfully wander away, walk away, run away, escape, or otherwise leave the facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge and enter into a harmful situation. Review of the clinical record for Resident R80, revealed resident was admitted to the facility on [DATE], with diagnoses including Anxiety Disorder (a mental illness that causes 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 facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that physican orders were followed related to an indwelling urinary catheter for one of five residents reviewed with incontinence concerns (Resident R8). Findings include: Review of Resident R8's clinical record revealed that the resident was admitted to the facility on [DATE]. Diagnoses included Urinary Tract Infection, Cognitive Communication Deficit (a difficulty with communication that's caused by a disruption in cognitive processes. This can affect a person's ability to speak, listen, read, write, and interact socially) and Depression (a common mental health condition that can impact a person's thoughts, feelings, behavior, and sense of well-being. It's more than just feeling down or having a bad day, and it can interfere with daily activities like sleeping, eating, and working). Review of physician order for Resident R8, dated August 23, 2024, indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of nutritional care and services, interviews with staff, reviews of policies and procedures, it was determined that the facility failed to assess and monitor the nutritional status of one of four residents reviewed to ensure that each resident maintained acceptable parameters of nutritional status related to usual body weight and laboratory values. (Resident R27) Findings include: A review of the policy titled weight management dated July 15, 2029 revealed that if there was a weight change from the previous weight for a resident that was less five pounds the dietitian was to be notified by the nursing staff. The dietitian was then responsible to conduct a nutritional assessment of the resident and provide interventions for the resident to maintain body weight and meet food and fluid needs daily. A review of the policy titled nutritional assessment dated [DATE] revealed that the dietitian in conjunction with the nursing staff and physician were to conduct a comprehensive assessment of each…

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 clinical records and interview with staff, it was determined that the facility failed to administer oxygen as ordered by the physician for one of 31 residents reviewed. (Resident R22) Findings include: Review of Resident R22's clinical record revealed that Resident R22 was admitted to the facility on [DATE], with diagnoses of Type 2 Diabetes Mellitus without complications, Acute Embolism and Thrombosis of unspecified deep veins of left lower extremity, obesity, Essential Hypertension, Unspecified Fracture of Left Lower Leg. Further review of resident's clinical record revealed a physician's order dated September 26, 2024, for: O2 (oxygen) at 2L via NC (nasal cannula) for Pox (pulse oxygen level) < 92% on room air every shift for Pox < 92% on room air. Observation on Resident R22 conducted during tour of the second-floor unit on October 21, 2024, at 1:04 pm, revealed that Resident R22 was in bed asleep with family member (son) on bedside. Further observation revealed that 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 review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to ensure provide documentation of a clinical rationale for the continued administration of an antipsychotic medication and failed to ensure that a gradual dose reduction was attempted for a psychoactive drug for one out of two residents reviewed (Residents R32) Findings Include: Review of facility policy Medication Monitoring and Management, effective dated September 6, 2023, revealed if a resident is admitted on an antipsychotic medication or the facility initiates antipsychotic therapy, the facility must attempt a Gradual Drug Reduction (GDR involves the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) in two separate quarters (with at least one month between the attempts) within the first year, unless clinically contraindicated. After the first year, a GDR must be attempted…

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 staff and resident interview, it was determined that the facility failed to ensure that all drugs and biologicals were safely stored for one of 31 residents reviewed (Resident R36). Findings include: Review of Resident R36's clinical record revealed that Resident R36 was admitted to the facility on [DATE] with diagnoses of Atherosclerosis Heart Disease, Type 2 Diabetes Mellitus, Occlusion and Stenosis of Bilateral Carotid Artery, Essential Hypertension, Hyperlipidemia, Further review of Resident R36's clinical record revealed the following physician's orders: Aspirin Oral Capsule 81 MG (Aspirin) Give 81 mg by mouth one time a day for CAD (coronary artery disease)-Order Date-September 27, 2023. Lasix Oral Tablet 20 MG (Furosemide) Give 1 tablet by mouth one time a day for LE (lower extremity) edema-Order Date-October 24, 2023. Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 25 mg by mouth one time a day for HTN (Hypertension) hold for sbp…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews with residents and staff, reviews of policies and procedures, and clinical record reviews, it was determined that the facility failed to provide as needed dental services for one of 31 clinical records reviewed. (Resident R56) Findings include: A review of the facility policy titled dental services dated December 2016 revealed that routine and emergency dental services were provided for all residents to meet their oral health needs. The policy indicated that a dentist provides care to the residents at the facility and was under a contracted agreement to visit the residents monthly and weekly as necessary. The policy indicated the the social worker was responsible for assisting residents with dental appointments and transportation arrangements to a dental office as needed. Clinical record review revealed a comprehensive annual assessment dated [DATE] that indicated Resident R56 was cognitively intact. Interview with Resident R56 at 9:30 a.m., on October 22, 2024 revealed that this 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.

Based on review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to ensure that physician orders were accurate for one of 31 residents reviewed (Resident R32). Findings include: Review of physician order dated March 13, 2024, for Resident R32, indicated an order to change oxygen tubing/cannula/plastic bag and inspect filter and clean or replace if soiled, weekly on Saturdays 11-7 shift; place initials and date changed the tubing that are placed in plastic bags; every night shift every Saturday. Check Pulse Ox every shift; Oxygen: 2 Liters/Minute, As Needed, via Nasal Canula for Pulse Ox below 92% Room Air, As Needed. Observation conducted on October 24, 2024, at 9:07 a.m., of Resident R2, in the presence of a Registered Nurse, Employee E9, revealed that Resident R32 had no oxygen devise placed with him as ordered. Interviewed with Resident R32 at the time of observation, revealed that he was not receiving or in need of any oxygen therapy for a long time. Reviewed the Minimum Data Set (MDS, a standardized way to evaluate…

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

Based on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to Transmission Based Precautions for one of 13 residents reviewed ((Resident R8). Findings include: Review of facility policy, Infection control Guidelines for all Nursing Procedures, effective dated October 2018, revealed that Transmission Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection. Standard Precautions apply to body fluids. Wear personal Protective Equipment (PPE) to prevent exposure to spills or splashes of body fluids. Observation on October 24, 2024, at 8:46 a.m. revealed that Employee E9, a Registered Nurse (RN) , examined the urinary Foley catheter of Resident R8. Employee E9 did not wear PPE during examinationo of the urinary catheter even though Resident R8 was suggested for Transmission Based Precautions. Employee E9 confirmed not wearing PPE 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.

Based on clinical record review and interviews with staff, it was determined that the facility failed to ensure that residents were provided with education related to the influenza vaccines prior to administration of the vaccine for six of six residents reviewed (Residents R2, R22, R29, R36, R83 and R115) Findings include: Review of clinical records of Resident R2, Resident R29, Resident R83, Resident R36, Resident R115 and Resident R22 revealed that all six residents were offered and received the flu vaccines for the flu season 2024-2025. Further review of Resident R2, Resident R29, Resident R83, Resident R36, Resident R115 and Resident R22's clinical record, revealed no documented evidence that that Resident R2, Resident R29, Resident R83, Resident R36, Resident R115 and Resident R22 were provided with education related to the influenza vaccines such as the benefits and potential side effects of the vaccines prior to administration of the influenza vaccines. Interview with the Director of Nursing (DON) Employee E2 conducted on October 24, 2024, at 12:25 p.m. confirmed that…

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

Based on observations of the operations of the main dietary kitchen and the six kitchenettes constructed on the nursing units, reviews of manufactures' specifications for the dish machines and interviews with staff, it was determined that essential mechanical equipment used for the food and nutrition services department was not fully operational and safe. Findings include: Observations of the dish machine area equipment inside the main kitchen revealed a dish machine whose manuafacturer's recommendations for safe operation were for hot water to be used for the cleaning and sanitation of dishes utencils bowls cups and every day china. The director of Dietary Services, Employee E3, reported that the booster heater required mechanical equipment (pressure reducing valve on the booster heater) and repair for the dish machine to be maintained safely and in accordance with manufacturer's specified final rinse temperature of 180 degrees Fahrenheit. Observations of the second floor B wing nursing unit kitchenette revealed a dish machine that was not maintained according to manufacturer'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 review of the nursing assessment tool, review of clinical records, and staff interviews, it was determined that the facility failed to permit the readmission of a hospitalized resident without providing evidence that the facility was not able to meet the resident's needs for one of three residents reviewed for hospitalizations (Resident 106). Findings Include: Review of the facility nursing assessment tool (determines what resources are necessary to care for residents during day-to-day operations and used to make decisions regarding capabilities to provide services to the residents in the facility), reviewed by the facility November 17, 2023, revealed common diagnoses include impaired cognition, mental disorder, and behavior that needs interventions. Further review of the nursing assessment tool revealed the average or range of residents with behavioral health needs was twenty-five. Review of Resident R106's clinical record revealed the resident was admitted to the facility, from the hospital, on November 8, 2023, with a diagnosis of dementia (the loss of cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop comprehensive person-centered care plans related to respiratory care, pain management, and falls for four of twenty-four residents reviewed (Resident R97, R76, R102, and R83.) Findings Include: Review of facility policy Care Plans, Comprehensive Person-Centered, revised December 2016, revealed the comprehensive person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of Resident R97's medical diagnoses in the Medication Administration Record (MAR) on January 8, 2024, revealed a diagnosis for sleep apnea (a sleep disorder in which breathing repeatedly stops and starts). Review of Resident R97's MAR for January 2024, revealed a physician's order dated November 11, 2023, for continuous positive airway pressure machine (CPAP - 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 clinical record review and interviews with staff, it was determined that the facility failed to ensure that adequate personal hygiene and grooming was maintained related to incontinence care and meal administration for one out of 24 residents reviewed. (Resident R91) Findings include: Review of facility's 'Activities of Daily Living (ADL's), Supporting,' revised March 2018, states Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care and c. Elimination, and d. Dining (meals and snacks). Review of facility provided grievance report dated October 9, 2023, revealed that on October 9, 2023 at 3:15pm, R91 was noted looking disheveled while in bed. Her daughter reported that half of a sandwich from lunch was found on her mom's bed covers. When the CNA from 3 to 11 shift provided incontinence care at 3:15 pm, dry bowel movement was found on R91.…

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, review of facility policies, and interviews with staff, it was determined that the facility failed to provide adequate supervision to prevent accidents hazards for one of eight residents reviewed (Resident R 83), who sustained frequent unwitnessed falls. Findings include: Review of facility policy titled Fall Risk Assessment revised March 2018 states the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Review of residents R 83s clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of muscle weakness, abnormality of gait and mobility, and dementia (Dementia is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).…

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 and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents maintained acceptable parameters of nutritional status, by failing to ensure timely notification of the physician for one of eight residents reviewed. (Resident R20). Findings include: Review of the facility's policy titled Weight Assessment and Intervention Policy revised 2008 revealed that any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. The policy also states that the dietitian will respond within 24 hours of receipt of written notification. Review of resident R 20's clinical record revealed that Resident R20 was admitted to the facility November 28,2023 with diagnosis's of hemiplegia( a symptom that involves one sided paralysis effect either the right side or left side of the body) and hemiparesis(muscle weakness on one side of the…

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

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 ensure a licensed pharmacist conducted a medication regimen review at least monthly for two of five residents reviewed (Resident R62 and R3). Findings Include: Review of the undated facility policy Consultant Pharmacist and Reports revealed the consultant pharmacist will review the medication regimen of each resident at least monthly and submit a written report of findings and recommendations resulting from the review. Interview on January 4, 2024, at 2:30 p.m. with the Nursing Home Administrator, Employee E1, surveyor requested the last six months (July 2023 through December 2023) of monthly medication regimen reviews that were completed by the consultant pharmacist for Resident R62 and R3. Review of Resident R62's clinical record revealed the resident was admitted to the facility on [DATE]. Further review of clinical record revealed no documented evidence the pharmacist completed 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 review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to ensure that an as needed psychotropic medication was limited to 14 days, without a documented rationale for continued use for one of five residents reviewed (Resident R3). Findings Include: Review of facility policy Antipsychotic Medication Use, revised December 2016, revealed residents will not receive PRN (as needed) doses of psychotropic medications (can treat a persons mood, behavior, perception, and thoughts) unless that medication is necessary to treat a specific condition that is documented in the clinical record. Further review of the policy revealed the need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale and duration for the extended order. Review of Resident R3's quarterly Minimum Data Set (federally mandated resident assessment and care screening) dated October 24, 2023, revealed the resident had a diagnosis of dementia (caused by damage to or loss of nerve cells 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 review of clinical record, facility documentation, review of facility policy and staff interviews, it was determined that the facility failed to report an alleged incident of neglect to the State Agency as required for one of seven clinical records reviewed. (Resident R1) Findings Include: Review of facility policy titled, Falls- Clinical Protocol last revised March 2018, states 7. Falls should also be identified as witnessed or unwitnessed events. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE] with a diagnoses of Raynaud's syndrome without gangrene, presence of right artificial hip joint, muscle weakness, essential hypertension, rheumatoid arthritis, Sjogren syndrome, and osteoarthritis. Review of MDS (Minimum Data Set) dated December 12, 2023 for Resident R1, the Cogntive Patterns section showed a BIMS (Brief Interview for Mental Status) of 99 indicating severe cognitive impaitrment. Review of nursing progress note from November 30,…

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, observations, and staff interviews, it was determined that the facility failed to ensure that a resident receive treatment and care in accordance with professional standards of practice by failing to notify a physician timely of a change in condition. (Resident R1). Findings Include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE] with a diagnoses of Raynaud's syndrome (blood vessels in your fingers and toes temporarily overreact to low temperatures or stress) without gangrene, presence of right artificial hip joint, muscle weakness, essential hypertension, rheumatoid arthritis, Sjogren syndrome (a long term autoimmune disease that affects the body's moisture-producing glands) and osteoarthritis. Review of Resident R1's admission Minimum Data Set (MDS) showed a Brief Interview for Mental Staff (BIMS) dated December 12, 2023, revealed that the resident was assessed with severe cognitive impairment. Review of Resident R1'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.