York Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record, observations, and staff interviews it was determined that the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for one of 36 residents reviewed (Resident R135).Findings Include:Review of Resident R135's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated October 3, 2025, revealed the resident had diagnoses of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), muscle weakness, and muscle wasting.Further review of Resident R135's comprehensive MDS dated [DATE], revealed the resident had severe cognitive impairments.Review of Resident R135's hospital discharge instructions dated October 21, 2024, revealed Resident R135 was found to have a fracture in the vertebral column that was further assessed by the orthopedic team. Recommendations from the orthopedic team included a thoracic lumbar…

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, observations, and staff and resident interviews it was determined that the facility failed to ensure residents received proper treatment and care to maintain good foot health for one of 36 residents reviewed (Resident R44).Findings Include:Review of Resident R44's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 29, 2025, revealed the resident was cognitively intact and had diagnoses of cerebral palsy (neurological condition that affects movement and posture) and muscle wasting.Review of Resident R44's comprehensive care plan revised July 3, 2025, revealed the resident had an activity of daily living self-care performance deficit related to weakness and impaired mobility.Interview on December 15, 2025, at 11:30 a.m. Resident R44 expressed he/she has been requesting to see podiatry for months. Observations revealed Resident R44's had long toenails, up to 1/2 inch long. Further the bottom of Resident R44's feet were dry and peeling.Observations on December…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility to ensure that residents were properly supervised. This resulted in an Immediate Jeopardy situation for a resident, who had had a diagnosis of dementia and history of exit seeking behaviors, to exit and elope from the building.Findings Include:Review of the job description of the Nursing Home Administrator (NHA) revealed that, the employee assumes full-time administrative authority, responsibility and accountability for the operations of the nursing facility. The employee manages facility employees in the provision of care and services rendered in accordance with professional standards, and in compliance with state and federal laws and regulations. The employee implements operational and financial objectives of management and allocates resources in an efficient and economical manner to attain…

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, interview, and record review it was determined that the facility failed to maintain and implement infection control program related to handwashing for one of thirty-six residents observed (Resident R47). Observation on Resident R47 conducted on December 2, 2025, during mediation administration revealed that Employee E32 administered Artificial Tears to the resident's right and left eye.Further observation revealed that Employee E32 did not perform hand hygiene between administering eye drops to the right and left eyeFurther observation revealed that Employee E32 administered Oxymetazoline HCl 0.05% Nasal Spray to Resident R47 left and right nostrils. Further observation revealed that Employee E32 did not perform hand hygiene prior to administering the nasal spray and between administration to left and right nostrils.Interview with Employee E32 confirmed that she did not sanitize her hands during administration of artificial tears between the left and right eyes and that she did not sanitize her hands during administration of Oxymetazoline HCl 0.05% Nasal Spray…

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, employee interviews and a review of facility policies, it was determined that the facility failed to maintain the dish machine in a safe operating condition.Findings include: A review of the undated facility policy, Chlorine Sanitizer Test Procedure revealed that staff should verify that dish machine is operating properly and allow it to run one full cycle and if the test strip reveals a chlorine reading below 50 parts per million (ppm) to notify the supervisor, adjust the sanitizer feed and retest. Observations during the initial tour of the kitchen on December 15, 2025, at 10:00 a.m. with Employee E14, Food Service Director (FSD), which revealed that the dish machine final rinse gage was reading between 140 degrees. The FSD indicated that the dish machine was a chemical sanitizing low temperature machine. Testing of chemical sanitizing dish machine with chlorine test strips revealed that no sanitizer was present in the final rinse confirming that the machine was not sanitizing the dishes that were being run through. After several attempts to adjust 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 interviews, review of facility policy and the review of facility documentation, it was determined that the facility failed to ensure one resident was free from misappropriation of resident funds and exploitation for one out of two residents reviewed (Resident R1). Findings include: Review of the facility Abuse policy with a review date of July 22, 2025.residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. Review of the August 2025 physician orders for Resident R1 included the diagnoses of heart failure (a syndrome caused by an impairment in the heart's ability to fill with and pump blood); hypertension (high blood pressure); cerebral infarction (a stroke); depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and age-related cognitive decline. Review of documentation…

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, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for three of 10 residents reviewed. (Resident R3, Resident R6, Resident R7) Findings include: Review of facility policy titled, Food Temperatures, dated January 17, 2019, revealed, All hot food items must be cooked to appropriate internal temperatures, held and served from steam table at temperature of at least 135° F. Take temperatures often to monitor for safe temperature ranges of at or below 41 ° F for cold foods and at or above 135° F (Fahrenheit) for hot foods. Continued review revealed, Hot food items may not fall below 135° F after cooking and all cold food items must be maintained and served at a temperature of 41 ° F or below. Interview with Resident R6 on April 1, 2025 at 10:00 a.m. revealed some food does not have flavor. Interview with Resident R7 on April 1, 2025, at 10:10 a.m. revealed the food is warm, not hot. Interview with Resident R3 on April 1, 2025, at 1:30 p.m. revealed, they never…

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 ten residents reviewed (Residents R112, R121, R60, R56 and R32). Findings include: Interview with Resident R112 on January 28, 2024, at 10:55 a.m. revealed that since the new people took over in the kitchen, they keep bringing me breakfast items with pork, like bacon. I cannot eat pork, they know I cannot have pork it makes me sick, why do they do this? I do not eat a lot of the food it just is not good, especially at night, and the nurse has to go down to the kitchen for two sandwiches every night either grilled cheese or turkey, why can't they just send me two sandwiches on my tray so that she does not have to go all the way down there every night? Interview with Resident R121 on January 28, 2024, at 11:00 a.m. revealed that food does not look right, I can't eat the platters, so I have to ask for sandwiches, I get 2 grilled cheese sandwiches for supper,…

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 the physical environment, interviews with staff and reviews of the pest control operators reports, it was determined that the facility was not maintaining an effective pest control program. Findings include: Based on observations of the physical environment interviews with staff and reviews of the pest control operators reports, it was determined that the facility was not maintaining an effective pest control program. A review of the facility policy titled Pest Control dated, April 1, 2022, revealed Bedrock Care shall maintain an effective pest control program. On January 28, 2025, at 10:49 a.m. observation of 2 flies were seen on the 1st floor South nursing unit. On January 28, 2025, at 11:32 a.m. interview with Resident R4 revealed an observation of a fly in the room. Resident R4 reported that flies are often present. On January 28, 2025, at 12:14 p.m., an observation of the lunch meal service on the second floor near room [ROOM NUMBER] revealed the presence of flies around the tray…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that a resident's right to request or refuse medical treatments were accurately reflected in the resident's record for one of 35 residents reviewed (Resident R96). Findings include: Review of Resident R96's clinical record revealed that the resident was admitted to the facility on [DATE] with a diagnosis of dementia (progressive degenerative disease of the brain). On December 13, 2024 the resident was placed on hospice care. Further review of Resident R96 clinical record revealed the resident's advanced directive remained full code. On January 31, 2025 at 2:12 p.m., interview with Unit Manager Employee E14 confirmed and stated that Resident R96's POLTS (Physician Orders for Life-Sustaining Treatment- a medical form that outlines a patient's end-of-life care preferences) should have been discussed on December 13, 2024 when the resident went on hospice care and it was not…

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 resident and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for two of four nursing units. (First floor South and North Nursing Units). Findings include: The facility's policy titled Resident's Rights-Safe/Clean/Comfortable/Homelike Environment dated April 1, 2022, indicated It is the policy of the facility to provide a safe, clean, comfortable homelike environment such as manner to acknowledge and respect residents' rights. On January 28, 2025, at 11:33 a.m. observation in room [ROOM NUMBER] bed C revealed dirty privacy curtains with brown spots and black strikes on both sides of the curtain. On January 28, 2025, at 12:25 p.m., an observation was conducted with the Maintenance Director, Employee E18, in room [ROOM NUMBER]B. The inspection revealed a loose closet door with two hinge screws that were not secure, as well as cracks in the wall around the heater that were not sealed. On January 28, 2025, at 1:06 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 facility policy review, personnel file review, and staff interview, it was determined that the facility failed to perform criminal history background checks prior to hire for one of five personnel files reviewed (Employees 2). Findings Include: The facility policy titled Employment Screenings for Potential Hires: Pennsylvania dated, April 2, 2022, revealed under Procedure B. section Criminal records check: i. in accordance with Act 13 and the Older adults Protective Services Act, the Facility will conduct a Criminal History Check as a condition of employment within the first 30 days of hire. This includes clearance through the Pennsylvania State Police. Review of the personnel file for Director of Nursing, Employee 2 revealed hiring date on November 11, 2024. Further review indicated that a Pennsylvania State Police background check was completed on January 29, 2025. An interview was conducted with the Nursing Home Administrator, Employee E1, on December 31, 2025, at 11:48 a.m. Employee E1 stated that the Human Services Director, Employee E9 had conducted a criminal…

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 clinical records, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of two residents reviewed regarding a smoking (Resident R192) Findings include: Facility policy entitled, Base Care plan, Comprehensive Care Plan and Ongoing care Plan Updates Revised October 1, 2024, revealed The facility will follow a uniform process for initiating the baseline care plan upon admission, the comprehensive care plan upon CCA (Care Area Assessment) completion, and ensuring care plan updated to reflect the resident's status. Resident R192's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of dementia (progressive degenerative disease of the brain), mild cognitive impairment of uncertain or unknown etiology, adjustment disorder with mixed anxiety and depressed mood, and memory deficit following a nontraumatic intracranial hemorrhage. Additionally, the resident was identified as 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 clinical record review, observations, resident and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for two of 35 residents reviewed (Resident R114, and R60). Findings include: On January28, 2025, at 12:34 p.m. Resident R114 was observed to have long and dirty nails on his hands. Resident R114 reported that he prefers his nails to be cut short. Review of Resident R114's most recent annual Minimum Data Set (MDS) dated [DATE], revealed him as totally dependent on one staff physical assistance for his activities of daily living. The resident's (BIMS - Brief Interview for Mental Status - a screen used to assist with identifying a resident's current cognition) indicated Resident R114 has intact cognition. A review of the comprehensive care plan for Resident R114 dated September 22, 2022, indicated Resident R114 has potential for impairment to skin integrity r/t…

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 review, clinical records review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the resident environment was free of accident hazards for one of 35 residents reviewed (Resident 35). Findings include: The facility's policy titled Resident's Rights-Safe/Clean/Comfortable/Homelike Environment dated April 1, 2022, indicated It is the policy of the facility to provide a safe, clean, comfortable homelike environment such as manner to acknowledge and respect residents' rights. On January 28, 2025, at 12:21 p.m., an observation in Resident R35's room revealed a long electrical extension cord with five outlets plugged into a wall outlet behind the resident's bed. The cord extended across the room to power a television placed on a dresser. During an interview, Resident R35 stated that they had purchased the extension cord for their television and video player, with the facility's permission. On January 28, 2025, at 12:25 p.m., an observation was confirmed by the Maintenance Director, Employee E18, who…

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

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 identify, implement, monitor, and modify interventions consistent with the residents needs and current professional standards of practice, to maintain acceptable parameters of nutritional status for one of eight residents reviewed. (Resident R67) Findings: Review of facility policy titled Weight Assessment and Intervention dated February 2022 revealed the nursing staff and dietician will communicate to prevent, monitor, and intervene for undesirable weight loss for the residents. The dietician will review monthly weights and determine if significant weight loss has occurred. Significant weight loss is defined as more or less 5% one month, and more or less 10% within 6 months. The dietician with the interdisciplinary team will make recommendations and care plan interventions. Review of Resident R67's annual Minimum Data Set (MDS- a federal mandated assessment for residents) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for three of 35 residents reviewed (R31, R88, R163). Findings include: Review of the Facility Policy and Guidelines for Implementation of Oxygen Administration, dated June 2016, indicated that the nurse should review and follow the physician's orders while administering Oxygen via nasal canula. Review of Resident R163's clinical record revealed; the resident was initially admitted to the facility on [DATE]; diagnosed with Acute Respiratory Failure with Hypoxia (a condition where the lungs are unable to adequately exchange oxygen, leading to low blood oxygen levels {hypoxia}, which can occur suddenly (acute) or develop over time (chronic, causing significant breathing difficulties and potential complications depending on the severity and duration of the issue; essentially, it means the body isn't getting enough oxygen due to…

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's job descriptions and personnel files, as well as staff interviews, it was determined that the facility failed to check the annotation list which becomes available on quarterly bases to verify the nurse aide certification to be valid to allow individuals to work as a nurse aide for one of three nurse aides reviewed (Employee E8). Findings include: The facility policy titled Employment Screenings for Potential Hires: Pennsylvania dated, April 2, 2022, revealed Prior to an offer of employment, the hiring manager should ensure all candidates for employment are properly interviewed and the following screens are completed: a. Attempt for two former employee references: i Ideally verification should include: 1. Dates of employment 2. Position held 3. Salary or hourly wage rate; i. When there is no prior employment, references can be obtained from schools, churches, or personal associations. a. Verification of license or certification if applicable The facility's job description for Nurse Aide, undated, revealed that a nurse aide certification was necessary…

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 resident clinical records, interview with staff, it was determined that the facility failed to develop a comprehensive person-centered care plan relating to post traumatic stress disorder (PTSD) for two of two residents reviewed with this diagnosis of PTSD. (resident R 139, and R157) Findings include: Review of facility policy titled Trauma informed care dated October 24th, 2022, revealed that the facility ensures that residents who are trauma survivors receive culturally competent, trauma informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause traumatization of the resident. This includes training and assisting staff to create an environment where the resident feels safe. The facility will assess each resident to ensure they receive the appropriate treatment and services. The facility will ensure employees have education training or in…

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

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: A tour of the Food Service Department was conducted on January 28, 2025, at 10:00 a.m. with Employee E3, Food Service Director (FSD), revealed the following concerns: Observation in the receiving dock revealed dozens of empty plastic 5 gallon chemical containers sitting outside the loading dock door. Observation in the walk-in freezer revealed a bag of frozen French fries with hole in bag, and a box of frozen peanut butter cookie dough open to the circulating air. Observation in the walk-in cooler revealed a yellow substance spilled on floor which had cracks in the steel plating with sharp rusty edges with food substances in the cracks. The broken flooring moved as weight was put on it causing a tripping hazard. Observation of the floor in the corner next to the prep sink revealed a thick black substance on the floor. Observation in the 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 review of clinical records , interview with staff and facility policy, it was determined that the facility failed to maintain complete and accurate records for one of 35 resident records reviewed (Resident R603). Findings include: Review of facility policy titled, Charting and Documentation, dated April 1, 2022 states, Observations, medications administered, services performed, etc., will be documented in the resident's clinical records. Resident R603 was admitted to the facility on [DATE] diagnosed with unspecific dementia with unspecified severity with agitation. Review of Resident R603 nursing progress note dated, January 20, 2025 indicated 500 milligrrams (mg) of acetaminophen was given to Resident R603 when the resident complained of pain. Interview with Licensed Practical Nurse (LPN) Employee E17 confirmed the acetaminophen was given at approximatley 2:00 p.m. with a positive effect and was sleeping at 3:30 p. m. before the nurse ended her shift. Further review of Resident R603 electronic…

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 and procedures, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices related to the use of appropriate protective equipment for wound care of two of two residents observed. (resident R4 and R 171). Findings: Review of facility policy titled Isolation Steps; Categories of Transmission-Based Precautions revised September 26th, 2022, revealed standard precautions shall always be used when caring for residents regardless of suspected or confirmed infection status. Transmission based precaution shall be used when caring for residents who are documented or suspected to have communicable disease or infections that can be treated submitted to others. Enhanced barrier precautions expand the use of personal protective equipment (ppe) beyond situations in which exposure to blood and bodily fluids is anticipated and refers to the use of gowns and gloves during high contact resident care activities that provide…

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 staff interviews, reviews of facility documents and observation, it was determined that the facility failed to ensure that air temperatures were maintained in two of two resident rooms observed (room [ROOM NUMBER] and room [ROOM NUMBER] Findings include: The Facility policy titled Air Temperature last revised 11/24/2020 revealed The facility is required to maintain an ambient temperature throughout residents and patient areas in temperature range of 71-81 degrees Fahrenheit (F) or at more restrictive range requirement by state or local requirements. On January 14, 2025, at approximately 9:20 a.m., an interview with Administrator Employee E1 revealed that the facility experienced a malfunctioning central heater in the first south hallway, which provides heat to the hallway. During maintenance checks, it was discovered that PTAC units in Rooms 239, 119 were not functioning. The windows were covered with plastic. Further investigation into the central heating issue revealed that the rooftop unit…

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 ensure that one of 12 residents reviewed was able to received visitors. (Resident R1) Findings include: CMS issued guidance to the previously released QSO-NH-20-39 originally issued on 9/17/20 and revised on 11/12/21 regarding visitation in nursing homes. This revised guidance stated that, Visitation is now allowed for all residents at all times This will be implemented immediately by nursing home facilities. Review or Resident R1's Quarterly Minimum Data Set (MDS-federal mandated process for clinical assessment for all residents) dated May 2, 2024, revealed that Resident R1 entered the facility February 18, 2024, with diagnoses of anemia (blood disorder occurring when the blood lacks adequate healthy red blood cells), hypertension (also known as high blood pressure is a condition in which the blood pressure in artery is persistently elevated), diabetes mellitus (a metabolic disease involving inappropriately elevated blood glucose levels), hyperlipidemia (a chronic…

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

Based on interviews with staff, reviews of clinical records, policies and procedures and review of the office of Long-Term Living Bulletin, it was determined that the facility failed to conduct an accurate Pennsylvania Preadmission Screening Review for one of four residents. (Resident R94) Findings include: A review of the facility policy and procedure titled Pre-admission Screening and Resident Review Program dated April 1, 2022 revealed that it was the responsibility of the facility to assure that all residents admitted to the facility receive a screening and review in accordance with State and Federal Regulations. Reviews of the office of Long- Term Living Bulletin revealed that the Pennsylvania Department of Human Services had a revised form (PASRR level 1) dated March 1, 2024. The form indicated the facility was responsible for adding a list of mental health diagnoses to the preadmission screening form for each resident, if applicable. Clinical record review for Resident R94 revealed the the Pennsylvania Preadmission Screening Review (PASRR) form for this resident was not…

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 clinical records and interview with staff, it was determined that the facility failed to ensure that resident received medication in accordance with physician orders for one of 35 residents reviewed. (Resident R49) Findings include: Review Facility Policy on Administering Medications dated April 1, 2022, revealed that under section Policy: Medications shall be administered in a safe and timely manner and as prescribed. Under section Protocol #2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and or have related functions. #3 Medications must be administered in accordance with orders, including any required time frame. #4 If a dosage is believed to be inappropriate or excessive for a resident or a medication, has been identified as having potential adverse consequences for the resident, or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or medical director to discuss…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and reviews of policies and procedures, it was determined that the failed to ensure that devices to promote healing of pressure ulcers were implemented for one of two residents reviewed. (Resident R93) Findings include: Review of the facility policy titled wound prevention dated April 1, 2022, revealed that all residents would have pressure relief implemented daily. The residents were to have a pressure redistribution mattress, mobility as tolerated, positioning and repositioning devices and supports, keep the sheets dry and stretch to avoid wrinkles and wheelchair cushions as needed. Clinical record review revealed a quarterly assessment (MDS-an assessment of care needs) dated February 20, 2024, indicated Resident R93 was admitted to the facility on [DATE]. The assessment also revealed that Resident R93 was cognitively impaired and with a diagnosis of Huntington's disease (an incurable neurodegenerative disease, caused by a gene defect). This assessment indicated…

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

Based on clinical record reviews, interviews with residents and staff and policy and procedure review, it was determined that the facility failed to ensure that each resident maintained acceptable parameters of nutritional status for usual body weight, laboratory values and nutritional assessment for one of five residents reviewed. (Resident R5) Findings include: Reviews of the facility policy titled weight assessment and intervention dated February 15, 2022 revealed that the nursing staff and the dietitian were responsible for assessment, prevention and monitoring of residents to prevent undesirable weight loss. If a significant weight loss occurs the dietitian with the interdisciplinary team will develop a care plan to meet the nutritional needs of the resident. Clinical record review revealed weights recorded for Resident R5 as follows: April, 2024 a weight of 182 pounds, March, 2024 a weight of 201 pounds, February, 2024 a weight of 198 pounds, January, 2024 197 pounds. The resident was recorded as 64 inches in height. The weights revealed a significant weight of 7.5% over three…

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 upon observation, interviews with staff, review of clinical records and facility policy, it was determined that the facility did not ensure residents who needed respiratory care related to supplemental oxygen was provided care by failing to follow physician orders for two of 35 resident records reviewed (Resident R21 and R107). Findings included: Review of facility policy on oxygen administration with review/update date of 2016 revealed that under section Purpose: To facilitate breathing by providing supplemental oxygen to residents. Under section Procedure: #1. Review physician's orders, #5. Turn oxygen on the prescribed amount. Test the oxygen that it is coming out of the mask or cannula. Review of Resident R107's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnosis of Chronic Obstructive Pulmonary disease (lung disease) and was dependent on supplemental oxygen. Review of Resident R107 physician orders dated, January 2, 2024, instructed to use 2 liters 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 clinical record review and staff interview, it was determined that the facility failed to ensure timely delivery of medications for one of 35 residents reviewed. (Resident R49) Findings include: Review of Resident R49's clinical record revealed that Resident 49 had diagnoses of hypertension (high blood pressure), and Lymphedema (swelling of the legs or arms). Review of Resident R49's physician orders revealed, and order dated April 26, 2022, for Amlodipine Besylate Tablet 10 milligrams give 1 tablet by mouth one time a day for HTN (Hypertension-High blood pressure). Review of Resident R49's April 2024 Medication Administration Record (MAR) revealed an entry for Amlodipine Besylate Tablet 10 milligrams (mg) give 1 tablet by mouth one time a day for HTN -Start Date of April 27, 2022. Further the Amlodipine was signed and coded 9 for April 17, 2024, at 9:00 a.m. Review of MAR chart code revealed that 9 was the code for other/see progress note. Review of nurses notes revealed that the medication Amlodipine 10 mg was not available for administration to Resident R49. Medication…

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

Based on observation, staff interview and review facility policy, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for one of two medication rooms observed. Findings include: Review of facility policy for controlled substance log dated April 24, 2023, revealed that under section policy . shall comply with all laws, regulations and other requirements related to receiving, handling, storage, disposal and documentation of Schedule 2 and other controlled substances. Under section Guidelines Storage and Maintenance of Controlled Drugs. #7 Maintain controlled drugs in a double locked box slash cabinet separate from other medications. Observation of the first floor medication room on April 17, 2024 at 9:27a.m. with Director of Nursing, Employee E2 revealed that an unopened vial of 5 ml Lorazepam Intensol 2mg/ml oral concentrate, for Resident R471. The vial was in the refrigerator but was not inside the locked box that was permanently affixed to the refrigerator. The 5 ml vial 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 the review of facility documents and resident clinical record and staff 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 two of three residents reviewed (Resident R153 and R148). Findings Include: Review of Resident R153's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated October 5, 2023, revealed the resident was admitted to the facility on [DATE], and had a diagnosis of schizophrenia, major depressive disorder, unspecified dementia, without behavioral disturbance psychotic disturbance, and mood disturbance and anxiety. Review of Resident R148's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 27, 2024, revealed the resident was admitted to the facility on [DATE], and had a diagnosis of bipolar disorder, delusional disorders, and unspecified dementia. Further review of the MDS, Section C -…

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, clinical record review and interviews with staff, it was determined that the facility failed to administer oxygen therapy in accordance with professional standards of practice and failed to obtain physician orders for oxygen therapy for one of one resident reviewed. (Resident R1) Findings Include: Review of Resident R1's care plan dated December 6, 2023, revealed that the resident had a diagnosis of pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred. This thickened, stiff tissue makes it harder for the lungs to work properly), sarcoidosis (disease characterized by the growth of tiny collections of inflammatory cells) and respiratory illness which required the resident to need oxygen therapy. Observation on March 8, 2024 at 9:40 a.m. revealed resident sitting on the side of the bed, wearing oxygen with a nasal cannula at 4 liters/min with a humidification bottle. Humidification bottle and oxygen tubing noted to have no date or time on them. Interview with Resident R1 on March 8, 2024 revealed that he fills up his…

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

Based on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food was distributed at appropiate temperatures on one of four nursing units. (1st Floor South unit) Findings include: A review of facility policy titled, Food Temperature effective date January 17, 2019, indicated that all hot food items must be cooked to appropriate internal temperatures, held and served from steam table at temperature of at least 135 degrees Fahrenheit (F). Take temperatures often to monitor for safe temperature ranges of at or below 41 degrees Fahrenheit (F) for cold foods and at or above 135 degrees Fahrenheit (F) for hot foods. On February 22, 2024 at 12:26 p.m. an interview with Resident R1 revealed food temp sometimes it's warm but most of the time it's cold. On February 22, 2024, at 12:35 p.m. an interview with Resident R2 revealed food temp sometimes it's warm or cold. On February 22, 2024, at 12:35 p.m. an interview with Resident R3 revealed food temp sometimes it's warm and sometimes it's cold. On February 22, 2024, at 12:57…

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 resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior on two of two nursing units (First and Second floor nursing units). Findings include: Observation during tour of residents' room accompanied with Maintenance Director Employee E 17, on October 27,2023 at 1:25 p.m. revealed Resident R62's room had a malfunctioning toilet, Resident R186's door to enter the room, did not close completely. Continued tour of the unit reveled that Resident 151 complained of having no heat. Employee E17 assessed the heater unit inside the room and found that it did not function properly. The unit was found not turning on. Further evaluation of the unit revealed that Resident R160 also had a heater unit that did not work, and a sink that did not drain properly. Employee E17 confirmed and listed all items that needed to be fixed. During an interview on October 25, 2023 at 10:30 a.m. with Resident R99, the resident was observed…

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, review of facility policies and staff interviews, determine the facility failed to prevent misappropriation of resident's medications for two of 38 resident records reviewed (Resident R259 and R260. Finding include: Review of the facility's abuse police revised on October 2022 states Abuse and Neglect exists in many forms, the policy defines misappropriation of resident property the deliberate misplacement exploitation or wrongful temporary or permanent use of a resident's belongings or money without resident's consent. Review of the facility's documentation revealed Resident R259 had a physician order for the narcotic medication Oxycodone 5 milligrams (mg) for pain. The same documentation stated, on May 25, 2023, the pharmacy delivered 58 tablets of Oxycodone 5 mg for the resident. The 58 tablets of Oxycodone were documented in the facility's narcotic book as being received on page 15 which included Resident R259's name and the name/strength of the medication. The 58 tablets were added to the resident's current supply of 7 tablets,…

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 staff, review of the clinical record and review of facility documents, it was determined that the facility failed to ensure a complete and through investigation to rule out abuse/neglect for an injury of an unknown origin for 1 out of 38 residents reviewed (Resident R108). Findings include: Review of the facility's policy undated policy, Abuse, indicated that it is the policy of the policy of the facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown sources) are promptly and thoroughly investigated. The policy also indicated that the investigation of abuse will include interviews with who was involved, the resident's statement if he/she is interviewable, resident roommate statement if applicable, and involved staff and witness statement of the events. Review of Resident R108's October 2023 physician orders included the following diagnoses of dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function…

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 clinical records and facility policy and interviews with staff determined the facility failed to ensure a resident received necessary treatment and services consistent with professional standards of practice to prevent the development of a pressure ulcers for one of 38 resident records reviewed, (Resident R257). Findings include: Review of the facility's wound prevention policy dated April 2022 states the facility will assist in the care, services and documentation related to the occurrence, treatment and prevention of pressure related wounds. On admission the resident's skin will be evaluated utilizing a Braden Scale observation. All residents will have nursing care procedures implemented including pressure relief and skin prep to bony prominence's in areas of high friction and twice a day to heels. Review of Resident R257 clinical record revealed the resident was alert and oriented admitted on [DATE], for aftercare, following coronary bypass surgery, diagnosed with…

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 reviews, observations, review of facility policy and staff interviews, it was determined that the facility failed to properly supervise a resident to ensure a safe environment for one of 38 residents reviewed. (Resident R118). Findings include: The facility policy entitled Smoking Safety policy revised October 22, 2022, stated on the third page Smoking an lighting materials will be kept in a designated area and not in the resident's possession. Items will be labeled and clearly identified per resident. The smoking schedule also has a designated supervisor listed on the schedule. This includes e-cigarettes, batteries, and refill cartridges. At the end of the smoking period the materials will be collected ad returned to their appropriate location. Residents are not permitted to give other residents smoking material unless it is coordinated by the facility. Interview conducted with Resident R118 in his room on October 26, 2023, at 11:06 a.m. revealed resident had a pack of cigarettes in his pocket. Interview with license unit manager, Employee E6 on October 26,…

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 documentation, and interviews with staff and residents, determined the facility failed to ensure residents who require dialysis receive such services, consistent with professional standards of practice, and the comprehensive person-centered care plan, by failing to maintain ongoing documented communication with the dialysis center for continuity of care, failing to provide dialysis treatment and medication as ordered and failing to notify the physician when these orders were not followed, for four of six hemodialysis resident reviewed, (Residents R80, R24, R119 and R148). Finding includes Review of the facility's Dialysis policy dated April 2022 states the facility shall provide residents adequate management of Dialysis services . residents will attain or maintain the highest practical physical, mental and psychosocial well-being. The policy defines End-Stage Renal Disease (ESRD) the stage of renal impairment that is irreversible, permanent, requiring…

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

Based on interviews with residents and staff, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that medications were reordered and stocked in a timely manner for 1 out of 38 residents reviewed (Resident R24). Findings include: Review of the facility policy, Administering Medications, dated April 1, 2022 indicated that medications will be administered in a safe and timely manner, and as prescribed. Review of the October 2023 physician orders for Resident R24 included the diagnoses of diabetes (a group of diseases that that are characterized by high blood sugar levels), chronic kidney disease (a gradual loss of kidney function occurs over a period of time) and dependence on renal dialysis (a life-saving treatment for people with kidney failure, who cannot filter their blood naturally). Resident R24's physician orders also included a diagnosis for heart failure (a progressive heart disease that affects pumping action of the heart muscles and causes fatigue and shortness of breath) Review of July 2023 physician orders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews with staff, it was determined that the facility failed to follow physician orders related to blood sugar monitoring and weights for two of four residents reviewed (Residents R2 and R4). Findings include: Review of Resident R2's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 28, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose), cerebrovascular accident (damage to the brain from interruption of its blood supply), hemiplegia (paralysis), human immunodeficiency virus (HIV - damage to the body's immune…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with staff, it was determined that the facility failed to adequately monitor the nutritional and hydration status for two of four residents reviewed (Residents R2 and R4). Findings include: Review of Resident R2's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 28, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose), cerebrovascular accident (damage to the brain from interruption of its blood supply), hemiplegia (paralysis), human immunodeficiency virus (HIV - damage to the body's immune system 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 a review of clinical records and staff interview, it was determined that the facility failed to ensure communication with the dialysis provider for two of two residents on renal dialysis. (Resident R2 and Resident R4) Findings include: Review of Resident R2's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 28, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose), cerebrovascular accident (damage to the brain from interruption of its blood supply), hemiplegia (paralysis), human immunodeficiency virus (HIV - damage to the body's immune system…

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, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide meals at regular times on one of one nursing units observed. (2 North) Findings include: Observations on the 2 North nursing unit on August 21, 2023, at 9:40 a.m. revealed a large tray delivery cart with nine breakfast trays which had not been passed out yet. Further observation revealed staff actively passing these trays out to residents on the 2 North unit. Interview with Resident R8 in room [ROOM NUMBER]-A on 2 North on August 21, 2023, at 9:44 a.m. revealed that she was still waiting on her breakfast tray, which was delivered while we were talking. She stated that meals were regularly late, and that she got her lunch at 2:30 p.m. the other day, and that they brought her dinner tray a couple hours later and she was not hungry yet. She was very upset that she has to wait so long for her meals. Interview with Resident R7 in room [ROOM NUMBER]-B on 2 North on August…

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.