East End Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripheral inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) in accordance with professional standards of practice for one of three residents (Resident R84).Findings include: Review of the facility policy Administration of an Intermittent Infusion last reviewed 4/1/25, indicated am intermittent infusion allows the patient to be disconnected from the infusion/administration set between medication doses. Label medication/solution container and administration set with date, time and nurses initials. Review of the facility policy Midline Catheter Dressing Change last reviewed 4/1/25, indicated a sterile dressing change using a transparent dressing is performed upon admission. If transparent dressing is dated, clean, dry and intact the admission dressing change may…

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

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals properly andsecurely in one of five medications carts (fourth floor medication cart) and one of three medication rooms (fourth floor medication room).Findings include: Review of the facility policy General Dose Preparation and Medication Administration last reviewed 4/1/25, indicated facility staff should enter the date opened on the label of medication dates. Review of the facility policy Storage and Expiration Dating of Medications and Biologicals last reviewed 4/1/25, indicated the facility should ensure resident medication rooms are locked and do not contain non medication/biological items. Review of the facility policy Returning Medications to the Pharmacy last reviewed 4/1/25, indicated the facility should return medications with any associated paperwork to pharmacy immediately after such medications have been discontinued. Facility should securely store the medications to be returned to pharmacy until they are picked up by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, observations, staff, and resident interviews, it was determined that the facility failed to provide residents food products based on their preferences for one out of four residents (Resident R19).Findings include: Review of the clinical record indicated Resident R19 was admitted to the facility on [DATE], with diagnoses of depression, macular degeneration (an eye disease that affects central vision. This means that people with macular degeneration can't see things directly in front of them), and muscle wasting. Review of Resident R19's MDS dated [DATE], revealed the diagnoses were current. During an observation on 9/9/25, at 12:12 p.m. Resident R19 was sitting in front of their lunch tray and stated I don't know what I have, no one had told me. A biscuit was observed on Resident R19's plate. The resident's meal ticked said NO BREAD/NO PASTA. Resident R19 expressed frustration that the facility continuously fails to honor their food preferences of having no bread products.…

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, observation, and staff interviews it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of two medication carts (3 South medication cart). Findings include: A review of the state operations manual dated 8/8/24, Resident Rights section §483.10(h) Privacy and Confidentiality: The resident has a right to personal privacy and confidentiality of his or her personal and medical records. A review of the facility policy General Dose Preparation and Medication Administration dated 4/1/24, indicates observe each resident's privacy and rights in accordance with applicable law (e.g. knocking before entering, pulling the privacy curtains, informing resident what is to occur before administration, blocking unnecessary access to the MAR). During an observation on 10/1/24, at 9:01 a.m. the medication cart outside of resident room [ROOM NUMBER], in the corridor, was left unattended with a resident listing with identifiable and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels as per physician's order and failed to document appropriate interventions for a resident with hypoglycemia (low blood glucose), for two of four sampled residents (Residents R30 and R63). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop…

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, resident clinical records, and staff interviews, it was determined that the facility failed to properly assess pressure ulcers and update wound treatments for one of three sampled residents (Residents R30). Findings include: The facility Skin and wound management policy dated 9/19/24, indicated that skin care and pressure injury prevention includes providing routine skin care, conducting a full body assessment upon admission, offload heels for at risk residents, licensed nurse will complete a weekly skin check. Review of Resident R30's admission record indicated he was originally admitted on [DATE]. Review of Resident R30's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 8/20/24, indicated that he had diagnoses that included chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), diabetes (metabolic disorder impacting organ function related 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records, resident and staff interview, it was determined that the facility failed to provide adequate and timely podiatry care treatment for one of two residents (Resident R85). Findings include: The facility Admissions agreement: services of other providers policy dated 4/1/24, indicated that the facility will provide basic services. Routine personal hygeine services include nail hygiene services. The resident may receive services from outside providers in the facility, so long as the outside provider is properly licensed and certified under the law. Review of Resident R85's admission record indicated he was originally admitted on [DATE]. Review of Resident R85's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 8/5/24, indicated he had diagnoses that included sarcoidosis (an abnormal collection of cells in the lungs and lymph nodes), chronic obstructive pulmonary disease (COPD: a disease characterized by…

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 facility polices, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for one of two residents (Resident R84). Findings include: Review of facility policy Indwelling Urinary Catheter Care Procedure dated 6/1/24, indicated that clinical staff with demonstrated competence may provide urinary catheter care. Such care will help to prevent catheter association urinary infections and prolong the life of the catheter system. Ensure drainage bag is covered with a privacy-dignity cover. Review of Resident R84's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R84's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 9/25/24, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (a progressive…

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, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Resident R16 and R46). Findings include: Review of facility policy Oxygen Administration dated 4/1/24, indicated licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by the provider. Verify provider order. Cleaning: Change oxygen tubing weekly and document accordingly to facility policy. Review of facility policy Non-Invasive Positive Pressure Policy dated 4/1/24, indicated the facility will provide the machines. A licensed clinician trained in the proper setup procedure will make noninvasive positive pressure ventilation setting adjustments and provide ongoing assessment and documentation of the patient ' s condition. Cleaning: Cleanse hose weekly with soap and tap water-air dry. Wash mask with soap and water after each use, let air dry. Once dry store…

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 interview it was determined that the facility failed to label/date opened medications on one of two medication carts (3 South medication cart) and failed to properly store medical supplies and biologicals in one of two medication carts (3 South medication cart) and failed to secure treatment medications and supplies in one of two treatment carts. (3rd floor treatment cart). Findings include: A review of the facility policy General Dose Preparation and Medication Administration dated 4/1/24, indicates facility staff should enter the date opened on the label of medications with shortened expiration dates (e.g., insulins, irrigation solutions, etc.). A review of the facility policy Storage and Expiration Dating of Medications dated 4/1/24, indicated facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medications and biologicals are stored. Facility should ensure that medications and biologicals have an expired date on the label. Once any medication or biological…

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, observation, clinical record review, and staff interviews, 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 two laundry room observations, failed to provide PPE (Personal Protective Equipment) signage which created the potential for cross-contamination and the spread of diseases and infections for one of two residents (Resident R51), failed to prevent cross contamination during a dressing change for one of three residents (Resident R16) and failed to prevent cross contamination during a medication pass for one of two residents (Residents R52). Findings include: Review of the facility policy Linen Management Policy dated 4/1/24, indicated linen will be handled, transported, and processed in a manner which reduces risk of contamination or cross contamination. The facility will handle all used linen as potentially contaminated and use stand precautions when handling, sorting, or…

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

Based on a review of facility policy, observations and staff interview, it was determined that the facility failed to properly label food products in the dry storage area and maintain sanitary conditions in the dish room and kitchen which created the potential for cross contamination in the designated main kitchen (Main kitchen). Findings include: A review of the facility Kitchen Sanitation policy dated 7/1/23 , indicated food and nutriton staff will maintain the sanitation of the kitchen. During an observation of the main designated kitchen on 10/30/23, at 8:50 a.m. the following was observed: - 3 bags of cheerios- no label - 2 bags of raisin bran cereal-no label - 1 bag of rice krispies- no label - 1 bag of corn flakes-no label During an observation of the main designated kitchen on 10/30/23, at 9:15 a.m. the following was observed: -Wall fan above clean side of dishwasher, brown debris -Ice machine in the main kitchen and in the dish room contained a brown substances inside the machine During an interview on 10/31/23 at 1:03 p.m. Maintenance Director Employee E5 confirmed the ice…

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 complete a Legionella assessment and plan, implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R279) and the facility failed to maintain a clean dryer filter to ensure linens and laundry are processed in accordance with accepted national standards for one of two dryers (Laundry room). Findings include: Review of the facility Legionella Assessment and Prevention Program policy dated 5/4/22, last reviewed 7/1/23, indicated the facility will ensure a Legionella assessment is conducted in accordance wit state and federal requirements for large, complex water systems. It was indicated the Adminstrator will assign a person responsible to complete the required Legionella assessment. Once the assessment is completed, a plan must be developed for areas identified that require a plan. It was also indicated that the facility will conduct annual testing must be performed annually at four water sources…

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, documents and observations and staff interviews it was determined the facility failed to maintain an effective pest control program related to fruit flies in the kitchen (Main Kitchen). Findings include: Review of the Pest Control Policy dated 7/1/23, indicated routine pest control procedures will be in place to prevent pest infiltration. Fly strips are prohibited in the kitchen areas. Appropriate action will be taken to eliminate any reported pest situation in the department. During an observation on 10/30/23 at approximately 8:50 a.m. in the dishroom of the Main Kitchen there were three gold fly stick traps full of fruit flies, as staff were doing dishes several fruit flies were observed in the area. Review of provided documentation included pest-control logs dated from 7/20/23-10/6/23. Treatments to the dishwash area were provided on the following dates: 7/20/23 Spot treatment for fruit flies in dishwasher area. Floor drain in front of garbage disposal needs cleaned daily and fans left on to circulate air and dry up excess water. 8/3/23 Gold Stick fly…

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 Resident Assessment Instrument User's Manual (RAI), clinical record review and staff interview, it was determined that the facility failed to complete Minimum Data Set (MDS) assessments in a timely manner for one of six residents (Residents R71). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated [DATE], indicated In accordance with the requirements at 42 CFR §483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must complete MDS assessments in a timely manner. For a death in facility tracking records, the MDS completion date must be no later than seven days from the event date. Review of Resident R71's clinical record indicated she was admitted to the facility on [DATE]. Review of Resident R71's MDS dated [DATE], indicated diagnoses of high blood…

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 interview, record review, and state scope of practice, it was determined that the facility failed to follow professional standards of practice for to one of six residents reviewed (Resident R57). Findings include: Review of the facility's Registered Nurse Job Description, last reviewed 7/1/23, indicated the purpose of this position is to provide care to the residents to ensure that the highest quality of care is maintained at all times. Review of Resident R57's clinical record indicated an admission of 11/30/21, with diagnoses that included depression, muscle weakness, and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction (occurs when poor blood flow to the brain causes cell death) affecting right dominant side. Resident R57's Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs) dated 8/22/23, indicated the diagnoses were current. Review of Resident R57's physician order dated 10/2/23, indicated to administer one tablet of 60 milligrams 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, personnel files and staff interview it was determined that the facility failed to complete annual nurse aid employee evaluations for one of four sampled records (Nurse aide (NA) Employee E8). Findings include: The facility assessment dated 10/3/23, indicated that required in-service training for nurse aides must be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year, and address areas of weakness as determined in nurse aide's performance review. Review of NA Employee E8 personnel record indicated she was hired on 8/17/16. Review of NA Employee E8 personnel record did not include an annual performance evaluation for 2023. During an interview on 11/01/23, at 12:59 p.m. the Director of Human Resources/ Accounts Payable Employee E1 confirmed that the facility failed to complete annual nurse aid employee evaluations as required. 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon clinical record review, and staff interview, it was determined that the facility failed to ensure that any irregularities submitted in the medication regiment reviews (MRR) by pharmacy were acted upon for one out of two residents (Resident R10). Findings include: Review of Residents R10's admission record indicated he was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included high blood pressure, heart failure(a progressive heart disease that affects pumping action of the heart muscles), and coronary artery disease (a common term for the buildup of plaque in the heart ' s arteries that could lead to heart attack.) Review of Residents R10's MDS assessment dated [DATE], indicated that the diagnoses were current upon review. Review of Residents R10's care plans dated 9/17/23, indicated that Resident R10 had an alteration in his cardiovascular status due to tachycardia (heart rhythm disorder with heartbeats faster than usual, greater than 100 beats per minute), history 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 a review of facility policy, resident clinical record review, medication review, and staff interview it was determined the facility failed to label open medications with a date on one of three medication carts (Third floor Medication B-Cart). Findings include: Review of the facility policy Storage and Expiration Dating of Medications, Biologicals last reviewed on 8/7/23, indicated that the facility staff should record the date opened on the primary medication container. During an observation on 10/30/23, at 11:38 a.m., of the Third floor Medication B-cart, the following medications were opened and undated. -B-12 1000mcg -Acetaminophen 500mg -Geri-Kot 8.6 mg -Vitamin D3 125mcg -Fish Oil Soft Gel 1000mg During an interview on 10/30/23, at 11:42 a.m., Licensed Practical Nurse (LPN) Employee E2 confirmed the facility failed to make certain over the counter medications were dated once opened. During an interview on 10/30/23, at 2:20 p.m., the Director of Nursing (DON) confirmed that the facility failed to ensure all medications were stored and labeled properly in one of 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.

Based on review of facility documents and staff inteviews, it was determined that the facility failed to employ staff with the required skills and competencies to carry out the daily functions of the Dietary Department for three out of 12 months (August, September and October 2023). Findings include: A review of facility document Director of Dining Services Job Description indicated that a qualified candidate must have a B.S. degree in Dietetics or Foods and Nutrition, or certification as a Dietetic Technician. If a Dietetic Technician, must work under the direction of a Registered Dietitian per State requirement. During an interview on 10/31/23 at 10:56 a.m. Regional Registered Dietitian(RD) Employee E11 confirmed the Dietary Director started August 2023, he has experience in kitchen but not in nursing facilities and did not possess a Certified Dietary Manager certificate. A review of the Director of Dietary Services Employee E12 Personnel File revealed that Director of Dining Employee E12 did not possess a Certified Dietary Manager from the certifying board for dietary managers.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, resident clinical record and staff interview it was determined that the facility failed to ensure a representative signed a binding arbitration agreement on the behalf of residents lacking capacity to understand the agreement terms for two out of four sampled resident records (Resident R38 and Resident R60). Finding include: The facility Resident rights and facility responsibilities policy dated 7/1/23, indicated the facility policy is to comply with all resident rights. The facility Admissions agreement document dated 7/1/23, indicated that the resident representative to sign any and all documents that are a part of the admissions process to the facility on the resident's behalf. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact…

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 facility policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a physician order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for one of four residents (Resident R13). Findings include: Review of the facility's Hospice Care Policy dated 5/24/23, last reviewed 7/1/23, indicated the facility provides hospice services through collaboration with a Medicare certified hospice agency when ordered by the resident's physician. Review of Resident R13's clinical record indicated the resident was admitted to the facility on [DATE]. Diagnoses included anorexia (abnormal loss of appetite), dementia ( a decline in cognitive abilities that impacts a person's ability to perform everyday activities), and anxiety. Review of Resident R13's admission order from the resident's hospice provider dated 6/24/21, indicated the resident was admitted to their…

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.