Carnegie Park Post Acute

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on behavioral health for eight of ten staff members (Employee E11, E12, E13, E15, E16, E17, E18, and E19). Findings include: Review of the facility policy, In-Service Training, All Staff most recently reviewed 3/14/25, indicated all personnel will receive education and training related to resident care. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) Review of facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and resident and staff interviews, it was determined that the facility failed to notify the resident representative of changes in appointment and transportation times for one of four residents (Resident R69). Findings include: Review of the facility policy, Notification for Medical Appointments dated 3/14/25, previously dated 8/13/24, indicated when a medical appointment is scheduled: - Document the appointment details in the resident's medical record. - Notify the responsible party at least 48 hours in advance, unless the appointment is emergent. - Use the resident's preferred communication method (e.g., phone, email, written notice). The notification to the responsible party should include: - Date and time of the appointment. - Name and specialty of the healthcare provider. - Purpose of the appointment. - Any special instructions or preparations required. Review of the clinical record indicated Resident R69 was admitted to the facility on [DATE]. Review of…

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

Based on review of facility policy , observations, and staff interviews it was determined that the facility failed to maintain a homelike environment in the facility (resident dining rooms) for one of four resident dining locations (first floor nursing unit). Findings include: A review of the facility Homelike Environment Policy dated 3/14/25, indicated residents are provided with a safe, clean, comfortable environment and encouraged to use their personal belongings to the extent possible. During an observation of the facility on 4/14/25, at 10:00 a.m., the following was revealed: First floor resident dining room had a bed, mattress, and two treatment carts stored in this location. During an interview on 4/14/25 at 10:32 a.m. Employee E1 unit manager confirmed the bed, mattress, and two treatment carts were stored in this location. During an interview on 4/15/25, at 10:30 a.m., the Nursing home Administrator and Director of Nursing confirmed that the facility failed to maintain the facility in a homelike environment for one of four resident dining locations (first floor nursing…

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 facility provided documentation, it was determined the facility failed to provide a qualified professional to direct the activities program as required for one of 12 months (3/3/25 through 4/14/25). Findings include: Review of the Activities Director job description required Qualifications Certificates, Licenses, Registrations - Activity Director certificate. During an interview on 4/16/25, at 1:30 p.m. the Nursing Home Administrator (NHA) confirmed the facility failed to provide a qualified professional to direct the activities program for one of 12 months (3/3/25 through 4/14/25). 28 Pa Code 201.18(b)(3) Management. 28 Pa Code 201.18(e)(6) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and documents, clinical records, and staff interviews, it was determined that the facility failed to provide care and services after hospitalization for one of three residents (Resident R68). Review of the clinical record indicated that Resident R68 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/24/25, included diagnoses of anemia (too little iron in the body causing fatigue), chronic kidney disease (gradual loss of kidney function), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). Review of hospital discharge instructions dated 3/19/25, indicated for the facility to reinforce the dressing. No direction for changing the dressing was documented. Review of a progress note dated 3/20/25, at 9:07 a.m. indicated, Pt (patient) has dressing intact to RLE (right lower extremity). Orders state to reinforce only, DO not change until F/U (follow-up) appointment in 2…

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, clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for one of five residents (Residents R244). Findings include: Review of the facility policy, Pharmacy Services Overview dated 3/14/25, the facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. Review of the clinical record indicated Resident R244 was admitted to the facility on [DATE]. Review of the facility diagnosis list included chronic obstructive pulmonary disease (COPD - a group of progressive lung disorders characterized by increasing breathlessness), spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness), and chronic pain syndrome. Review of a physician's orders dated 4/11/25, indicated Resident R244 was to receive oxycodone…

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, observations, and staff interviews, it was determined that the facility failed to ensure that the call bell system was in full working order for one of four nursing units (Second Floor Nursing unit). Findings include: Review of the facility policy Call System, Residents 3/14/25, indicated that the call system communication will be audible and visual and the resident call system will be functional at all times. During an observation of the Second Floor Nursing Unit, central call bells identified in the A, B, and C halls did not illuminate when resident call bells in their rooms of each hall had been activated. During an interview on 4/15/25, at 9:10 a.m., the Director of Nursing confirmed that the central call bells were not functioning to provide unobstructed visual communication of which hall the call bell was coming from due to the ceiling bulkhead. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (b) (1) Management.

Based on observation and staff interview, it was determined that the facility failed to ensure a safe, functional and clean environment for two of 33 residents of the Third floor B wing nursing unit (Resident R99 and R112). Findings include: During an observation on 4/16/25, at 8:50 a.m., of the Third Floor Nursing Unit, two maintenance workers were observed exiting Resident R99 and R112's resident room. Upon entering the resident room, a four foot by four foot area (approximately) wall behind Resident R99's bed had been removed exposing wires and insulation. When asked, Maintenance Director Employee E7 stated that the wall had pulled away, from the television being too heavy and it needed repaired. Resident R99 and R112's belongings were scattered all over the room allowing debris to fall onto them and into their personal items. During an interview on 4/16/25, at 9:25 a.m., the Nursing Home Administrator confirmed that the facility failed to provide a safe, functional resident room for Residents R99 and R112. 28 Pa. Code: 207.2(a) Administrator's responsibility.

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Prevention of Abuse and Neglect for one of ten staff members (Employee E18). Findings include: Review of the facility policy, In-Service Training, All Staff most recently reviewed 3/14/25, indicated all personnel will receive education and training related to resident care. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) Review of facility provided documents and training…

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, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Employees Employee E11 and E15). Findings include: Review of the facility policy, In-Service Training, All Staff most recently reviewed 3/14/25, indicated all personnel will receive education and training related to resident care. Review of Nurse Aide (NA) Employees Employee E11 and E15 ' s education records, with hire date greater than 12 months, revealed the following: NA Employee E11 had a hire date of 3/26/23, with approximately four of in-service education between 3/26/24, and 3/26/25. NA Employee E15 had a hire date of 4/14/14, with approximately four hours of in-service education between 4/14/24, and 4/14/25. During an interview on 4/18/25, at approximately 1:00 p.m. confirmed that the facility failed to provide the required 12 hours annual in-service education within 12 months of their hire…

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 it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for five of ten residents (Resident R1, R2, R3, R4, and R5). Findings include: Review of Resident R1's admission record indicated he was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 11/5/24, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), high blood pressure, and edema (swelling caused by too much fluid trapped in the body's tissues). Review of an active physician order dated 9/6/24, indicated Resident R1 should have ACE wraps (stretchable elastic bandages) removed from both legs at the hour of sleep. No active order was noted to place ACE wraps on. During an observation on 12/11/24, at approximately 11:35 a.m. Resident R1 had the ACE wraps on both legs applied in the direction from the…

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

Based on review of facility policy and resident interviews and observations, it was determined that the facility failed to ensure sufficient staffing to meet resident need for ten of thirteen residents (Resident R2, R6, R7, R8, R9, and R10, and four confidential residents: RB, RC, RD, and RE). Findings include: Review of the facility policy, Answering the Call Light dated 7/13/23, indicated the facility will provide timely responses to the resident's requests and needs. During a group interview of five residents who requested confidentiality on 12/11/24, when asked if they felt the facility had sufficient staff, two of the five (Confidential Residents RB and RC) stated No. When asked if call light response times were overlong, four of the five confirmed that they were. Confidential Resident RB stated, We can't sit for hours with a wet diaper. We aren't animals. Confidential Resident RC stated, I've waited six hours. Confidential Resident RC further stated that she has been told by staff that they don't have time to take her to the bathroom, and she needs to have her bowel movement…

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

Based on a review of facility documentation, cited deficiencies from previous surveys, review of plan of correction documentation, and staff interview, it was determined that the facility ' s Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. This has the potential to affect 16 of 140 residents. Findings include: Review of the facility policy Quality Assurance and Performance Improvement (QAPI) Program dated 8/13/24, indicated objectives of the QAPI program include providing a means to establish and implement performance improvement projects to correct identified negative or problematic indicators and to establish systems through which to monitor and evaluate corrective actions. The facility ' s deficiencies and plan of correction for the State Survey and Certification (Department of Health) survey ending 3/22/24, revealed the facility developed a plan of correction that included quality assurance systems to ensure the facility maintained compliance with cited nursing home regulations. Review of the plan of correction 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 observation, manufacturer ' s instructions, and staff interviews, it was determined that the facility failed to consistently maintain an infection prevention and control program, which ensured proper cleaning and disinfecting of glucometers (a device used to test the amount of sugar in a person's blood) to prevent the potential for cross-contamination for one of three medication carts (Third Floor Cart Rooms 308-321). Findings include: Review of the guidance released by the U.S. Food and Drug Administration on 10/29/20, indicated that 70% ethanol solutions are not effective against viral bloodborne pathogens. Review of the Centers for Disease Control and Prevention's document titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration last reviewed 2/6/13, indicated that if blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. Review of the glucometer manufacturer's recommendation provided by the facility revealed…

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

Based on observation and staff interviews, it was determined that the facility failed to ensure a clean, sanitary, functional environment in the main laundry room. Findings include: During observation of the main laundry room on 7/9/24 at 2:00 p.m., revealed that there are three professional commercial sized washing machines and three commercial sized dryers. Only one of the three washing machines was functional, and two of the three dryers were functional. The soiled linen holding area had approximately eight bags of soiled linen laying in the laundry chute, and over 15 bags of soiled linen, and a large bin of overflowing soiled linen waiting to be laundered. There was a strong odor of feces and urine noted. During an interview with The Director of Housekeeping and Laundry Employee E1 on 7/9/24 at 1:15 p.m., revealed We are getting it done, but not fast enough. Some of the bags that are piled up will have to be thrown out. It has been like this since I started in February. During an interview with laundry aide Employee E2 on 7/9/24, at 2:00 p.m. revealed The washers have been out…

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 and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to be aware of resident's departure from the facility for one of seven residents (Resident R1). Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 2/11/24, included diagnoses of high blood pressure and obesity. Review of an Elopement Risk Assessment completed on 11/10/23, indicated Resident R1 was not risk for elopement. Review of Resident R1's plan of care for Potential for Discharge initiated 11/9/23, indicated that Resident R1 will be discharged home when clinical and rehabilitation goals are met. Review of a progress note written by the Director of Nursing, dated 3/31/24, at 1:16 p.m., written on 4/1/24, at 11:20 a.m., indicated Resident returned from LOA (leave of absence) with son around 10:30 pm on Easter…

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 dish machine temperature/sanitation logs, observations, and staff interviews, it was determined that the facility failed to follow proper sanitation and temperature procedures for the dish machine operation allowing for the potential for cross contamination in the main kitchen for seven of nine months (July 2023, August 2023, October 2023, November 2023, January 2024, February 2024 and March 2024). Findings include: During a observation of the staff use of the low temperature dish machine, the Assistant Dietary Manager Employee E4 stated that she did not know what the temperatures of the dish machine wash should be or the sanitation level that is required to make certain the dishes and items being washed were sanitized and clean for resident use. During an review of the dish machine temperature logs from January 2024 through March 2024. The previous logs from July 2023 through December 2023 identified wash temperatures required to be 120 degrees and sanitation levels at 50 to 100 parts per million (PPM). Further review of the logs indicated the following: July…

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, resident group meeting and resident and staff interview, it was determined that the facility failed to demonstrate a response to grievances for resident group meeting for five of six residents held during the annual survey (Residents R100, R101, R102, R103, R104). Findings include: A review of the facility grievance procedure policy last reviewed on 1/23/24, with a previous review date of 7/19/23, indicated that all concerns can be written and placed in the concern form collection box and five locations identified or residents can seek out Administration team or staff member with concerns. Concerns presented to the Administrator is typically responded to within 72 hours. During the Resident Council Meeting on 3/20/24, at 10:15 a.m., the resident consensus indicated that they have no idea who the grievance officer is and they do not know where and how to file an anonymous grievance and they have told staff about issues and have never heard back from anyone when they have brought concerns up. Staff just tell them they'll get back to them and don'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy and clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for eight of the twelve residents reviewed (Resident R16, R21,R29, R32, R39, R44, R47, R67, R68, R127, R134, R142). Findings Include: A review of the facility policy Advanced Directives on 7/19/2023, 1/23/2024, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. A review of the medical record indicated Resident R16 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure and…

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

Based on the facility policy, observations, Resident group meeting and staff interview, it was determined that the facility failed to provide residents access to grievance forms, failed to provide the right to file grievances anonymously, and failed to post the name of the Grievance Official for residents to file a grievance orally (meaning spoken) for 155 of 155 residents at the facility. Findings include: A review of the facility grievance procedure policy last reviewed on 1/23/24, with a previous review date of 7/19/23, indicated that all concerns can be written and placed in the concern form collection box and five locations identified or residents can seek out Administration team or staff member with concerns. Concerns presented to the Administrator is typically responded to within 72 hours. The posted procedure indicated the second previous Administrator as the grievance officer. Review of the facility Resident admission Packet indicated that the facility follows the resident rights of being able to file a grievance. During an observation on 3/19/24, from 9:00 a.m. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of resident council meeting minutes, facility concern/grievance log and clinical records, and resident and staff interviews, it was determined that the facility failed to investigate potential abuse and/or neglect for three of 35 residents(Resident R209, R302 and R37). Findings include: Review of the facility Abuse Prohibition policy reviewed on 1/23/24, with a previous review date of 7/19/23, indicated that the facility Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, injuries of unknown origin, etc. The facility will protect the residents from further abuse during investigation and the investigation will begin within 24 hours. All allegations will be reported to the state agencies in accordance with state law. Review of the clinical record indicated Resident R209 was admitted to the facility on [DATE], with diagnoses which included sepsis(infection), breast cancer, cute kidney failure, acute…

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 it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for four of four residents (Resident R20, R45, R83, and R145). Findings include: Review of Resident R20's admission record indicated he was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 3/7/24, included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels) and a seizure disorder. Review of an active physician order dated 3/10/24, indicated Resident R20 should have ACE wraps applied to both legs, on in the morning and off at the hour of sleep. During an observation on 3/20/24, at approximately 11:35 a.m. Resident R20 had his ACE wraps applied in the direction from the knees to the toes. Review of Resident R45's admission record indicated she was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included…

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, Centers for Disease Control (CDC) documents, observations, and staff interview, it was determined that the facility to make certain that medications and medical supplies were properly stored and/or disposed of on one of two nursing units (Second-Floor Nursing Unit). Findings include: Review of the facility policy Storage and Expiration Dating of Medications, Biologicals dated [DATE], indicated the facility should ensure that: -Medications and biologicals are stored in an orderly manner. -External use medications and biologicals are stored separately from internal use medications and biologicals. -Medications and biologicals that have an expired dated on the label are stored separate from other medications until destroyed or returned to the pharmacy or supplier. Review of the CDC's NIOSH (National Institute for Occupational Safety and Health) List of Antineoplastic and Other Hazardous Drugs in Healthcare, 2016 dated [DATE], indicated that conjugated estrogens are Known to be…

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

Based on facility policy, observation, and staff interview, it was determined that the facility failed to provide a safe and sanitary environment to help prevent the potential for cross-contamination for two of four medication carts (2nd A/B Hall Treatment Cart and B/C Hall Treatment Cart). Findings include: Review of the facility policy Storage and Expiration Dating of Medications, Biologicals dated 1/23/24, indicated the facility should ensure that medications and biologicals are stored in an orderly manner and that external use medications and biologicals are stored separately from internal use medications and biologicals. During an observation of the 2nd A/B Hall Treatment Cart stored in the medical supply room, it was noted that the drawer containing treatment supplies was divided into four sections. Top, left section: (1) tube of triamcinolone (prescription skin cream) for Resident R112, not in a bag. (1) tube of Santyl (prescription wound ointment) for Resident R40, not in a bag. (1) tube of Premarin conjugated estrogen (prescription vaginal cream), for Resident R96, not in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interviews, it was determined that the facility failed to make certain that weight loss was identified and addressed and failed to identify needs for increased nutrition for one of five residents (Residents R78). Findings include: Review of Centers for Medicare and Medicaid Services GUIDANCE §483.25(g) indicated that significant weight loss is defined as: 5% or greater in one month 7.5% or greater in three months 10% or greater in six months Altered Nutrient intake, absorption, and utilization: Poor intake, continuing or unabated hunger, or a change in the resident's usual intake that persists for multiple meals, may indicate an underlying condition or illness. Examples of causes include, but are not limited to: -An inadequate amount of food or fluid, including insufficient tube feedings. -Diseases and conditions such as cancer, diabetes mellitus, advanced or uncontrolled heart or lung disease, infection and fever, liver disease, kidney disease, hyperthyroidism, mood…

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.