Highland Hills Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observations and staff interview, it was determined that the facility failed to determine whether it was safe to self-administer medications for four of seven residents (Resident R31, R40, R70 and R102). Findings include: Review of the facility policy Self-Administration of Medications dated 11/1/25, indicated residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Review of Resident R31's clinical record indicated an admission date of 2/11/21. Review of R31 's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/15/25, indicated diagnosis of anemia (low iron in the blood), heart failure (heart doesn't pump the way it should), and chronic obstructive pulmonary disease (COPD- causes breathing problems). Observation 12/16/25 at 9:15 a.m. indicated a bottle of nasal spray sitting on Resident R31's bedside stand. 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.

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 include hypoglycemia protocols for one of three sampled residents (Resident R19) and failed to obtain a physician order for three of four residents (Resident R10, R102 and R149). Findings include: Review of the facility policy Medication and Treatment Orders last reviewed 11/1/25, indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications. Review of Resident R10's clinical record indicated an admission date of 7/8/23. Review of R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated11/27/25, indicated the diagnosis of hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease (COPD- restricts breathing), and hyperlipidemia (high fats in the blood). Observation on…

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 four of six residents (Residents R10, R127, R158 and R172).Findings include: Review of the facility policy Respiratory Equipment Change and Cleaning Guidelines last reviewed 11/1/25, indicated handheld nebulizers (used to deliver respiratory medicine) are to be labeled and dated with the room number/bed, they are stored in plastic bag when not in use. Nasal cannulas (thin tubing placed in nostrils to deliver supplemental oxygen) are to be labeled and dated when changed and stored in plastic bag when not in use. Continuous Positive Airway Pressure (CPAP-keeps airways open when you sleep) or Bilevel Positive Airway Pressure (BIPAP-normalizes breathing by delivering pressurized air) are to be labeled with room number/bed and to be stored in a plastic bag when not in use. Review of Resident R10's clinical record indicated an admission…

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 facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R7) and failed to ensure that Enhanced Barrier Precautions were managed properly for three of three residents (Resident R16, Resident R89, and Resident R159).Findings include: Review of the facility policy Dressings, Dry/Clean last reviewed 11/1/25, indicated wash and dry hands thoroughly. Put on clean gloves, remove soiled dressing discard into plastic or biohazard bag. Wash and dry your hands thoroughly. Review of the facility policy Enhanced Barrier Precautions dated 11/1/25, indicated Enhanced Barrier Precautions (EBP's) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. Indwelling medical devices include central lines, urinary catheters, feeding tubes, 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 resident group meeting, clinical record review, observation and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R149).Findings include: Review of the clinical record indicated that Resident R149 was admitted to the facility on [DATE], with diagnoses which included hepatic encephalopathy (brain dysfunction caused by liver dysfunction), diabetes mellitus and morbid obesity. During an observation on 12/16/25, at 9:29 a.m. Resident R149's call light above her door illuminated, the call light was not responded to until 9:45 a.m., 16 mintute later, when Nurse Aide Employee E18 and Nurse Aide Employee E19. Review of facility provided documents Call Bell Audit's dated 12/11/15, 12/12/25, 12/16/25, revealed 12/11/25 room [ROOM NUMBER]: 21-minute response time, 12/12/25 room [ROOM NUMBER]: 20-minute response time, 12/16/25 room [ROOM NUMBER]: 16-minute response time. During an interview on 12/16/25, at 1:00 p.m. Registered Nurse…

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 facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide a Skilled Nursing Advanced Beneficiary Notice of Non-coverage (SNF-ABN) for one of three sampled resident records (Resident R134).Findings include:The facility Medicare Advanced Beneficiary Non-coverage notices policy reviewed 11/1/2024, indicated a resident is informed in advance and in writing when Medicare payment denial or change in coverage is likely. Written notices are provided to the resident as soon as the facility makes the assessment that Medicare payment certainly or probably will not be made.Review of Resident R134's admission record indicated he was originally admitted on [DATE] and readmitted on [DATE].Review of Resident R134's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 10/7/25, indicated he had medical diagnoses included 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.

Based on review of facility policy, resident council group interview, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of three common areas (Vending machine area).Findings include:The facility Homelike environment policy last reviewed on 11/1/25, indicated to provide a safe, clean and comfortable environment. Comfortable and safe temperatures include between 71 and 81 . During a Resident council group interview on 12/16/25, at 1:46 p.m. three out of eight residents voiced concerns that the Grand Heritage room with the vending machines was cold.During an interview on 12/17/25, at 9:35 a.m. Maintenance Supervisor Employee E25 stated: some of the heating units need replaced. It's been like this for a couple of months.During a tour of facility rooms and common areas on 12/17/25, at 9:36 a.m. observations of the vending machine rooms on Grand heritage found the room temperature to be 55 . During an interview on 12/17/25, at 2:45 p.m. information disseminated to the Director of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, facility documents, resident clinical records, and staff interviews it was determined that the facility failed to maintain an environment free of abuse for one of five sampled residents (Resident R167).Findings include:The facility Abuse, neglect, exploitation prevention program policy dated 11/1/25, indicated residents have the right to be free from abuse, neglect, exploitation.Review of Resident R167's admission record indicated she was admitted on [DATE] and readmitted on [DATE]. Review of Resident R167's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 11/26/25, indicated she had diagnoses that included dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), and hyperlipidemia (elevated lipid levels within the blood).Review of Resident R167's care plan 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 review of facility policy, clinical record review and staff interview, it was determined that the facility failed to conduct a thorough investigation of an injury obtained during care to eliminate possible neglect for one of five residents (Resident R11). Findings include: Review of facility Abuse, Neglect, Exploitation and Misappropriation Prevention Program last reviewed 11/1/25, indicated the program consists of a facility wide commitment and resource allocation to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident's property. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE]. Review Resident R11's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 11/20/25, indicated diagnoses of anemia (low iron in the blood), heart failure (heart doesn't pump the way it should) and seizure disorder (surge of abnormal electrical activity in the brain causing loss of consciousness 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 a review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) accurately reflected the resident's status for two of four residents (Resident R127 and R161).Findings include:The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of care needs), dated October 2025, indicated the following instructions:Intent: The intent of the items in this section (Section O) is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods. O0110: Special Treatments, Procedures, and Programs. Facilities may code treatments, programs and procedures that the resident performed themselves independently or after set-up by facility staff. Do not code services that were provided solely in conjunction…

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, facility policy, and staff interviews, it was determined that the facility failed to implement procedures to ensure the timely acquisition and administration of prescribed medications for one of six sampled residents (Resident R109).Findings include:The facility Pharmacy services policy last reviewed 11/1/25, indicated the facility shall accurately and safely provide and obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals. Pharmacy services consist of the residents having a sufficient supply of their prescribed medications and receive those medications in a timely manner.Review of Resident R109's admission record indicated he was originally admitted on [DATE] and re-admitted on [DATE].Review of Resident R109's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 8/12/25, indicated he had diagnoses that included end stage renal disease (gradual loss of kidney 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.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals properly and securely in two of five medications carts (first floor medication cart four and second floor medication cart two) and two of two medication rooms (first floor, and second floor medication rooms). Findings include: Review of the facility policy Medication Labeling and Storage last reviewed 11/1/25, indicated the facility stores all medications and biologicals in locked compartments. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Review of the facility policy Discarding and Destroying Medications last reviewed 11/1/25, indicated medications that cannot be returned to the dispensing pharmacy are disposed of in accordance with federal, state and local…

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 two of eight residents (Resident R149, R174). Findings include: Review of clinical record indicated Resident R149 was admitted to the facility on [DATE], with diagnoses of diabetes mellitus, morbid obesity and hepatic encephalopathy (brain dysfunction caused by liver dysfunction). Review of Resident R149's MDS dated [DATE], revealed the diagnoses were current. Review of R149 physician's orders dated 12/5/25 indicated allergies to chicken, fish, mushroom, turkey. Interview on 12/16/25 at 10:30 a.m. Resident R149 indicated the kitchen gives her only hamburgers when there is chicken, fish, or turkey on the menu even though they have an always available menu and that her family has to bring her food when there is chicken on the menu. Review of clinical record indicated Resident R174 was admitted to the facility on [DATE], 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 review of facility files and an interview with the Human Resources Director Employee E9, it was determined that the facility failed to employ a full-time qualified social worker from 7/27/25, through 9/2/25.Findings include: Review of facility provided payroll documentation on 9/25/25, at 10:00 a.m. Social Worker Employee E10's last day worked was 7/27/25. Review of facility provided payroll documentation on 9/25/25, at 10:00 a.m. Social Worker Employee E11's first day worked was 9/2/2/25. Interview with the Human Resources Director Employee E9 on 9/24/25, at 10:05 a.m. confirmed that the facility failed to employ a full time qualified social worker from 7/27/25, through 9/2/25. Pa Code 211.16. Social Services. Pa Code 201.14 (a)Responsibility of licensee.

Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on QAPI (Quality Assurance and Performance Improvement) for three of five employees (Nurse Aide (NA) Employee E15, and NA Employee E5, and Licensed Practical Nurse (LPN) Employee E16). Findings include: Review of the Facility assessment dated Quarter one 2025, indicated staff training/education and competencies will be completed during general orientation upon hire, annually, and as needed. Educations listed included:-Communication, resident rights and facility responsibilities, abuse, neglect and exploitation of residents, quality assurance and performance improvement (QAPI), infection control, compliance and ethics, and behavioral health. Findings include: Review of facility provided documents and training records for NA Employees E15 and NA Employee E5 and LPN Employee E16, failed to include education on QAPI as required. Telephonic interview on 9/25/25, at 9:52 a.m. Human Resource Employee E9 confirmed that the facility failed to provide training on QAPI 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, and facility provided documents, as well as staff interviews, it was determined that the facility failed to ensure that one of four residents (Resident R3) was free from abuse perpetrated by a resident with aggressive behaviors (Resident R1).Findings include: Review of the facility policy Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 11/1/24, indicated residents have the right to be free from abuse. This includes physical abuse. The prevention program consists of a facility wide commitment and resource allocation to support the following objectives: Protect residents from abuse by anyone including facility staff, other residents, etc. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of two allegations of abuse for two of three residents (Resident R1 and R3).Findings include: Review of facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy dated 11/1/24, indicated all reports of resident abuse, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/18/25, indicated the diagnoses of high blood pressure, dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough 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, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of abuse for two of three residents (Resident R1, and R3). Findings include: Review of facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy dated 11/1/24, indicated all reports of resident abuse, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/18/25, indicated the diagnoses of high blood pressure, dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe…

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, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of an elopement and possibility of neglect for one of three residents (Resident R1).Findings include: Review of facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy dated 11/1/24, indicated all reports of resident abuse, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/18/25, indicated the diagnoses of high blood pressure, dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe…

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 record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one of four residents (Resident R4).Findings include: Review of facility policy Assistive Devices and Equipment dated 11/1/24, indicated the facility maintains and supervises the use of assistive devices and equipment for residents. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/1/25, indicated diagnoses of stroke (damage to the brain from an interruption of blood supply), hemiplegia (paralysis of one side of the body), and aphasia (difficulty with either language or speech). Observation on 9/24/25, at 9:05 a.m. Resident R4 was observed in bed. A hand splint was noted in the bedside stand. Resident R4 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records and staff interviews, it was determined that the facility failed to provide sufficient and timely social services related to assistance in transferring to the Veterans Affairs (VA) for a behavioral bed for one of twelve residents (Resident R1).Findings include: Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/18/25, indicated the diagnoses of high blood pressure, dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), and insomnia (persistent problems falling and staying asleep) Section C0500 the Brief Interview for Mental Status (BIMS - is a screening test that aids in detecting cognitive impairment) indicated a score of eight - moderately impaired cognition. Section GG0170 Mobility indicated Section K. Walk 150 feet in a corridor or similar…

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 a job description, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) did not effectively manage the facility to make certain that proper supervision was provided for residents at high risk for elopement as required, resulting in a resident elopement creating an immediate jeopardy situation.Findings include: The job description for the NHA specified the primary purpose of the job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Based on the findings in this report that identified that the facility failed to effectively manage the facility to make certain that proper supervision was provided for residents at high risk for elopement as required, resulting in a resident elopement creating an immediate jeopardy situation. The facility failed to provide fundamental principal…

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 regulations, documents submitted to the State agency and staff interviews it was determined that the facility failed to notify the State agency of a change in the facility's Nursing Home Administrator (NHA) at the time of the change. Findings include: Review of the facility's password agreement document dated 9/16/25, indicated NHA became the Interim Administrator effective 9/5/25, and that they are responsible for submitting a Plan of Correction in response to deficiencies cited by the Pennsylvania Department of Health on CMS Form 2567. During an interview on 9/22/25, at 9:00 am the Director of Nursing confirmed that NHA Employee E14 was on leave and that the administrator for the facility was the Interim NHA. During an interview on 9/22/25, at 9:00 a.m. the Director of Nursing confirmed that on 9/5/25, the facility failed to notify by written letter the State Agency of the change of administrators which failed to meet the requirement of notification at the time of the change. PA Code: 201.14(a) Responsibility of licensee.

Based on review of facility education documents, and staff interview, it was determined that the facility failed to provide training on effective communication for two of five staff members (Nurse Aide (NA) Employee E15, and NA Employee E5). Findings include: Review of facility provided documents and training records for NA Employees E15 and NA Employee E5, failed to include education on effective communication as required. Telephonic interview on 9/25/25, at 9:52 a.m. Human Resource Employee E9 confirmed that the facility failed to provide training on effective communication for two of five staff members (NA Employee E15, and NA Employee E5). 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(6)(d) Staff development.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, incident reports, facility documents, employee statements, and staff interview it was determined that the facility failed to ensure that a resident received adequate supervision who was an elopement risk which resulted in an elopement for one of seven residents (Resident R1). This was identified for past non-compliance for Resident R1. Findings include: Review of facility policy Elopement indicated: It is the policy of this facility to protect residents from wandering away from the facility and to begin an immediate search if a resident is found missing. Review of Resident R1's admission record indicated they were admitted on [DATE]. Review of Resident R1's MDS assessment (MDS - Minimum Data Set - a periodic review of resident needs) dated 5/27/25, indicated diagnosis of unspecified dementia (a group of symptoms affecting memory, thinking and social abilities) and mood disturbance (disconnect between actual life circumstances and the persons' state of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for two of three residents reviewed (Resident R1 and R2). Findings include: Review of facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy dated 11/1/24, indicated all reports of resident abuse, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. Witness statements are obtained in writing, signed and dated. The witness may write statement, or the investigator may obtain a statement. Abuse, is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation,…

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, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of three allegations of abuse for two of three residents (Resident R1 and R2). Findings include: Review of facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy dated 11/1/24, indicated all reports of resident abuse, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. Witness statements are obtained in writing, signed and dated. The witness may write statement, or the investigator may obtain a statement. Abuse, is defined at 483.5 as the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical record, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of abuse for one of three residents (Resident R1). Findings include: Review of facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy dated 11/1/24, indicated all reports of resident abuse, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. Witness statements are obtained in writing, signed and dated. The witness may write statement, or the investigator may obtain a statement. Abuse, is defined at 483.5 as the willful infliction of injury, unreasonable confinement,…

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, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of three allegations of abuse for two of three residents (Resident R1 and R2). Findings include: Review of facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy dated 11/1/24, indicated all reports of resident abuse, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. Witness statements are obtained in writing, signed and dated. The witness may write statement, or the investigator may obtain a statement. Abuse, is defined at 483.5 as the willful infliction of injury, unreasonable confinement,…

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 notify a physician, failed to notify family, and failed to complete an assessment of a resident after an abuse allegation was made for three abuse allegations for two of three residents (Resident R1 and R2). Findings include: Review of facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy dated 11/1/24, indicated all reports of resident abuse, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. Witness statements are obtained in writing, signed and dated. The witness may write statement, or the investigator may obtain a statement. Abuse, is defined…

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 record, and staff interview, it was determined that the facility failed to develop a baseline care plan that included Life Vest (wearable defibrillator designed to protect residents from sudden cardiac death), and interventions needed to provide effective and person-centered care for two of two residents (Resident R1, and R2). Findings include: Review of facility policy Care Plans - Baseline dated 11/1/24, indicated a baseline plan of care should be developed for each resident within 48 hours of admission. The baseline care plan should include instructions needed to provide effective, person-centered care of the resident which includes initial goals based on admission orders. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/7/25, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods 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 a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for one of two residents (Resident R1). Findings include: Review of facility's policy Care Plans, Comprehensive Person Centered dated 11/1/24, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/7/25, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), coronary artery disease (damage or disease in the heart's major blood vessels), and high blood pressure. Review of Resident R1's 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 review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure a physician completed the initial comprehensive visit for three of six residents (Residents R3, R4, and R5). Findings include: Review of Resident R3's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/28/25, indicated diagnoses of high blood pressure, depression (a constant feeling of sadness, loss of interests), and muscle weakness. Review of Resident R3's clinical record indicated a History and Physical assessment (a comprehensive formal assessment) was completed by Certified Registered Nurse Practitioner (CRNP) Employee E12 on 1/22/25. Review of Resident R4's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R4's MDS dated [DATE], indicated diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other…

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 job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to ensure that nursing staff had the specific competencies and skill set necessary to provide care for residents with a Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death). Findings include: The signed job description for Nursing Home Administrator dated 11/1/24, indicated that this position's purpose is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. The signed job description for Director of Nursing dated 11/1/24, indicated the purpose of this position is to oversee and supervises the care of all the residents. This includes overall management of the entire nursing department, responsible for ensuring resident safety, and conduct in-services 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and a review of the facility's assessment it was determined that the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for its specific resident population. Findings include: Review of Resident R1's clinical record revealed a Printable Discharge Form dated 2/5/25, that included correspondence between the facility and the discharging hospital, in which the hospital had documented, Will you have a bed for this patient today? Patient will be coming with a Life Vest. On 2/5/25, at 10:15 a.m. the facility responded, I can take. Just let me know what time you get for transport please. Resident was accepted to facility and admitted [DATE]. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/7/25, indicated diagnoses of diabetes (a metabolic disorder 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records and staff interviews it was determined that the facility failed to make certain controlled substances were accounted for accurately for four of seven residents (Resident R1, R2, R3, and R4). Findings include: Review of the facility policy, Administering Medications dated 11/1/24, indicated, Medications are administered in a safe and timely manner, and as prescribed. Review of the clinical record indicated Resident R1 was admitted to the facility 11/27/24. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 11/29/24, included diagnoses of emphysema (a lung disease which results in shortness of breath due to over-swelling of the alveoli) and lung cancer. Review of a physician order dated 12/6/24, discontinued 12/10/24, indicated Resident R1 was to receive oxycodone ER (extended release) 20 mg every twelve hours. Review of a physician order dated 12/6/24, discontinued 12/10/24, indicated Resident R1 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations and staff interview, it was determined that the facility failed to properly store food products in dry storage, walk in cooler, reach in cooler and failed to maintain sanitary conditions in the dish room which created the potential for cross contamination (Main Kitchen). Findings include: Review of facility policy Sanitation dated 11/1/24 indicates the food service area shall be maintained in a clean and sanitary manner. During an observation of the main designated kitchen on 12/8/24, at 8:45 a.m. the following was observed: Walk in cooler: -ground beef (6) thawing on the 2nd shelf -deli turkey (1)- no date -bag salad mix (1) - no date Dry storage: -metal bowl of raisin bran, no cover, label, date -liquid better (3) - no date -oatmeal cream pies (23) - no date -[NAME] buddies (4) - no date Reach in cooler -American cheese (1) - no label or date -boiled eggs (1) - no label or date -hot dogs (2) - no label or date During an observation of the main designated kitchen…

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 provide a clean, safe, comfortable, and homelike environment for seven of 15 resident wheelchairs (Residents R4, R5, R9, R49, R69, R89, and R93), failed to maintain structure of wall surface in two area (Resident R144's room and Arcadia Unit Dining Room), failed to maintain an adequate supply of washcloths readily available for staff use on two of four units (LTC and TCC units), and failed to ensure the privacy curtains were clean and sanitary for two of ten resident rooms (Residents R81 and R124). Findings include: Review of the facility policy Cleaning and Disinfecting Residents' Rooms dated 11/1/24, indicated housekeeping surfaces (e.g. floors, tabletops, and wheelchairs) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. Review of the facility policy Quality of Life - Homelike Environment dated 11/1/24, indicated residents are provided with a safe, clean, comfortable, and homelike environment. Homelike setting…

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

Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for six of ten residents reviewed (Residents R2, R91, R107, R132, R256, and R259). Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that an admission MDS assessment was to be completed no later than 14 calendar days following admission (admission date plus 13 calendar days), and an annual MDS assessment was to be completed no later than the Assessment Reference Date (ARD) plus 14 calendar days. Resident R2 had an ARD of 11/14/24, with a complete by date of 11/28/24. A review on 12/10/24, revealed Resident R2's MDS had not been completed. Resident R91 had an admission date 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 the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that that quarterly Minimum Data Set assessments were completed within the required time frame for 21 of 38 residents reviewed (Resident R17, R29, R30, R32, R33, R34, R38, R51, R55, R61, R79, R97, R101, R102, R105, R117, R122, R123, R124, R127, and R136). Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that quarterly MDS assessments were to be completed no later than 14 calendar days after the Assessment Reference Date (ARD). Resident R17 had an ARD of 11/5/24, with a complete by date of 11/19/24. A review on 12/10/24, revealed Resident R17's MDS had not been completed. Resident R29 had an ARD of 11/3/24, with a complete by date of 11/17/24. A review on 12/10/24,…

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, clinical records, and staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans to meet care needs for two of four residents (Resident R139 and R143). Findings include: A review of facility policy Care Plans, Comprehensive Person - Centered dated 3/5/24, last reviewed 11/1/24, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of Resident R139's MDS (Minimum Data Set - periodic assessment of resident care needs) dated 10/15/24, indicates reentry to facility on 10/8/24, with the diagnosis of anemia (low iron in the blood) gastroesophageal reflux disease (GERD- stomach acid repeatedly flows back up into the esophagus causing heartburn and other problems) and anxiety. Section K - Swallowing/Nutritional Status, K0520B indicated Resident R139 had a feeding tube. Review of Resident R139's physician orders 11/25/24, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain that residents were monitored, assessed, and received the necessary services to prevent pressure ulcers/wounds from developing or worsening for three of three residents (Residents R140, R150, and R152). Findings include: Review of the facility policy Pressure Ulcers/Skin Breakdown-Clinical Protocol dated 11/1/24, indicated the nursing staff shall describe and document the following: full assessment of pressure sore including location, stage, length, width and depth, presence of exudate's (fluids released from a wound) or necrotic tissue (death of tissue through disease); pain assessment; resident's mobility status, current treatments, including support surfaces; and all active diagnoses. The staff will examine the skin of a new admission for ulcerations or alterations in skin. Review of the admission record indicated Resident R140 was admitted to the facility on…

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 facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that appropriate treatment and services were provided for two of four with an indwelling urinary catheter (Residents R12 and R97) and one of two residents with an external urinary catheter (R65). Findings include: Review of the facility policy Dignity dated 11/1/24, indicated each resident shall be cared for in a manner that promotes enhances resident sense of well-being, feelings of self-worth and self-esteem. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to help the resident to keep urinary catheter bags covered. Review of the admission record indicated Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/21/24, indicated the diagnoses of anemia (the blood doesn ' t have enough healthy red blood cells), obstructive uropathy (structural 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 clinical record review, observations, and staff interview, it was determined the facility failed to provide to provide appropriate care and services to residents receiving tube feedings for three or three residents reviewed (Residents R139, R143, and R259). Findings Include: Review of facility policy Enteral Nutrition dated 11/1/24, indicated that adequate nutritional support through enteral nutrition is provided to residents as ordered. The nurse confirms that orders for enteral nutrition are complete. Complete orders include: a. the enteral nutrition product; b. delivery site (tip placement); c. the specific enteral access device (nasogastric, gastric, jejunostomy tube, etc); d. administration method (continuous, bolus, intermittent); e. volume and rate administration; f. the volume/rate goals and recommendations for advancement towards these; and g. instructions for flushing (solution, volume, frequency, timing and 24 hour volume). Review of Resident R139's MDS (Minimum Data Set - periodic assessment of resident care needs) dated 10/15/24, indicates reentry to 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 record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained and failed to maintain an accurate care plan for dialysis access site for three of three dialysis resident (Resident R14, R33, and R48). Findings include: Review of the facility policy End-Stage renal disease, how to care for residents with dated, 11/1/24, indicated agreements between this facility and contracted ESRD facility include all aspects of how the resident's care will be managed including how information will be exchanged between facilities. Review of the admission record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/1/24, indicated the diagnoses of diabetes mellitus, dependance on renal dialysis, and end stage renal disease. Review of current physician orders on 9/24/24, indicated Resident R14 attends dialysis on…

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, observations, and staff interviews, it was determined that the facility failed to store medications properly and securely in three of six medications carts (LTC cart 1, LTC cart 2, and Grand Heritage cart) and medications found unsecured at resident's bedside for three of 10 residents (Residents R2, R105, and R110). Findings include: Review of the facility policy Medication Labeling and Storage dated 11/1/24, indicated multi-dose (used more than once) medications that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date. During an observation on 12/8/24, at 11:00 a.m. of LTC medication cart 1 indicated the following medications opened and undated: -Resident R66's Humalog insulin (a rapid acting insulin). -Resident R32's Solostar (prefilled pen to inject long-acting insulin under the skin). Interview with Licensed Practical Nurse (LPN) Employee E25 confirmed the medications for Resident R66 and Resident…

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

Based on review of facility policy, facility documentation, and resident and staff interviews, it was determined that the facility failed to address repetitive grievances/concerns voiced during resident council meetings and individual grievances for four of six months (August 2024, September 2024, October 2024, and November 2024). Findings include: Review of the facility policy Grievances/Complaints, Filing last reviewed on 3/5/24, and again on 11/1/24, indicated residents have the right to file grievances, either orally or in writing, to the facility staff. The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident. Review of facility provided grievance logs August 2024, through November 2024, indicated the following concerns: -Resident R9's family filed a grievance dated 8/5/24, that the Arcadia unit's appearance was inadequate, along with the cleanliness. -Resident R67 filed a grievance on 9/3/24, regarding availability of linens and washcloths. -Resident R43's family filed a grievance on 9/4/24, that the Arcadia unit floors…

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 Code of Federal Regulations (CFR), clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide timely notice of the Notice of Medicare Non-Coverage (NOMNC) for one of three sampled resident records (Closed Resident Record CR1). Findings include: Review of the CFR indicated at GUIDANCE §483.10(g)(17)-(18), the NOMNC, Form CMS-10123, is given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The NOMNC informs the beneficiaries of the right to an expedited review by a Quality Improvement Organization. Review of Closed Resident Record CR1's admission record indicated they were admitted on [DATE], with diagnoses that included breast cancer, atrial fibrillation (irregular heart rhythm), and heart failure (heart doesn ' t pump blood as well as it should). Review of Closed Resident Record CR1's Minimum Data Set (MDS - a periodic assessment of care…

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 record review, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for two of six residents reviewed (Residents R67 and R106). Findings include: Review of facility policy Abuse Prohibition dated 3/5/24, indicated neglect is defined as the failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of facility policy Safe Resident Handling/Transfer Equipment dated 3/5/24, indicated safe resident handling involves the use of assistive devices to ensure that patients can be transferred safely and that care providers avoid performing high risk patient handling tasks. The Total Lift is used for those patients who are dependent non-weight bearing or have inconsistent weight bearing. Review of the clinical record indicated Resident R67 was admitted to the facility on [DATE].…

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, observations, and staff interviews it was determined that the facility failed to ensure that residents received consistent post fall monitoring for two of seven residents (Residents R15 and R79). Findings include: Review of the facility policy Fall Management dated 11/1/24, indicated when a resident is found on the floor, the facility is obligated to investigate into how the resident got there and put into place an intervention to minimize it from recurring. This will be documented in the residents care plan and progress notes. Review of Residents R15's admission record indicated she was admitted on [DATE]. Review of Residents R15's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/2/24, indicated she had diagnoses that included diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids),…

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 related to oxygen/nebulizer management for two of three residents (Residents R39 and R121). Findings include: Review of the facility policy Oxygen Therapy - Mask and Cannula dated 11/1/24, indicated when masks and cannulas are not in use, store in a plastic bag obtained from central services. Change the humidifier water bottle every 10 days (Note: humidifier bottle must be dated). Review of the admission record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/30/24, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), stroke (damage to the brain from an interruption of blood supply), and high blood pressure. Review of Resident R39's physician orders dated 10/30/24, indicated albuterol sulfate…

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 record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R110). Findings include: Review of the facility policy Care Plans, Comprehensive Person Centered dated 3/5/24, last reviewed 11/1/24, indicates a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Review of the clinical record indicated Resident R110 was admitted to the facility on [DATE]. Review of Resident R110's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/16/24, indicated diagnoses of Post Traumatic Stress Disorder (PTSD- a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous…

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, meal observations, resident interviews, and staff interviews it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for five of five breakfast meal observations on the Arcadia Unit (12/8/24, 12/9/24, 12/10/24, 12/11/24, and 12/12/24). Findings include: The Facility Assessment document dated Quarter 4, 2024, indicated that facility has a wide range of cognitive needs including those that are memory impaired, with dementia or Alzheimer's, and mental issues. The facility Staffing, Sufficient and Competent Nursing policy dated 11/1/24, indicated that the facility provides sufficient numbers of nursing staff. Factors considered in determining appropriate staffing ratios and skills include and evaluation of the diseases, conditions, physical or cognitive limitations of the resident population, and acuity. Minimum staffing requirements imposed by the state, are adhered to when determining staff ratios…

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 staff interviews it was determined that the facility failed to provide adaptive feeding devices for one of three residents (Resident R87). Findings include: Review of the admission record indicated Resident R87 admitted to the facility on [DATE]. Review of Resident R87's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/14/24, indicated diagnoses of diabetes mellitus, irritable bowel syndrome, and chronic pain. Review Resident R87's physician order dated 10/22/24, indicated a CCD (Controlled Carbohydrate diet), regular texture, thin liquids. During an observation on 12/8/24, at 8:45 a.m. Resident R87's breakfast tray was observed on the bedside table. The meal ticket indicated sippy cup. During an interview and observation on 12/9/24, at 9:05 a.m. Registered Nurse (RN) Employee E17 indicated a sippy cup was not served as ordered on the tray, two regular cups were present. Interview on 12/9/24, at 2:15 p.m. the Nursing Home Administrator (NHA) confirmed the facility…

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

Based on review of facility documents and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for one of four quarters (April 2024, through June 2024). Findings include: Review of the CFR (Code of Federal Regulations) §483.75(g) Quality assessment and assurance. §483.75(g) Quality assessment and assurance. §483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (iv) The infection Preventionist. Review of Quality Assurance and Performance Improvement (QAPI) sign-in sheets and attendance records from the period of April 2024, through June 2024, did not reveal that the Medical Director/designee was in attendance. During an interview on 12/12/24, at…

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

Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions and failed to implement a care plan containing interventions for enhanced precautions which created the potential for cross-contamination and the spread of diseases and infections for one of four residents (Resident R139). Findings include: Review of the facilities policy Enhanced Barrier Precautions dated 3/5/24, last reviewed 11/1/24, indicates Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms to residents. EBP's are indicated for residents with wounds and /or indwelling medical devices. Review of Resident R139's MDS (Minimum Data Set - periodic assessment of resident care needs) dated 10/15/24, indicates reentry to facility on 10/8/24, with the diagnosis of anemia (low iron in the blood) gastroesophageal reflux disease (GERD- stomach acid repeatedly flows back up into the esophagus causing heartburn and other problems) and anxiety. Section K05208B 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and resident and staff interviews, it was determined that the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents (Resident R11). Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE], at 2:45 p.m. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 4/11/24 included diagnoses of fracture of sacrum (bone at bottom of spine), hypertension (high blood pressure), and depression. Review of Section J: Health Conditions revealed resident R11 is on a scheduled pain medication regimen. Review of Resident R 11's clinical admission dated 4/4/24, 2:45 p.m. section As3 indicated resident had vocal complaints of pain and was protective of body movements, location of pain lower back. Review of Resident R11's care plan for Pain related to fracture, back spasms 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.

Based on observations and staff interviews it was determined that the facility failed to provide accurate meal trays for one of two residents and failed to provide food products based off the resident's food preference for one of two residents (Resident R9). Review of facility policy Resident Rights, dated 2/1/23, last reviewed 3/5/24, indicates to incorporate each residents ' goals, preferences, and choices into care. Review 4/30/24, of Resident R9's breakfast tray card indicated that the resident was to receive two bananas with breakfast daily. Interview 4/30/24, at 11:55 a.m. Dietary manager Employee E14 confirmed Resident R9 has not been receiving bananas as ordered as they are only ordered every 3 weeks on Tuesdays. Interview with Registered Dietician Employee E13 also confirmed that Resident R9 has not received his bananas as ordered. Interview 4/30/24, at 11:57 a.m. the Director of Nursing confirmed the facility failed to provide accurate meal trays for one of two residents. Pa Code: 211.6(a) Dietary services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for two of seven residents (Resident R1 and R2). Findings include: Review of facility policy General Dose Preparation and Medication Administration dated 7/18/23, indicated facility staff should verify that medication name and dose are correct when compared to the medication order on the mediation administration record (MAR). Facility staff should [NAME] each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, and for the correct resident. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/23/24, indicated diagnoses of arthritis (inflammation of one or more joints, causing pain 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 review of facility policy, facility documents, meal delivery observations, resident group interview, resident and staff interviews it was determined that the facility failed to ensure that meals were served at regularly scheduled times for two out of five days (1/8/24 and 1/9/24). Findings include: The facility Meal times and delivery policy dated 5/1/23, and last reviewed 7/18/23 indicated that meals are provided at predictable times, three times a day, and food is delivered promptly in designated areas. Review of Food Cart Delivery Times indicated the following delivery times and locations: Breakfast is to be delivered to the Arcadia Unit 8:45 a.m.-8:50 a.m. Lunch is to be delivered to the Arcadia Unit 12:45 p.m.- 12:50 p.m. Review of a facility document dated 10/6/23, a resident representative voiced concern over timeliness of meals. Review of a facility document dated 10/13/23, a resident representative stated that dinner was late last night on 10/12/23, and that it is 10:00 a.m. and still has not received breakfast. Review of a facility document dated 11/15/23, stated…

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, resident group interview, resident interviews and staff interview it was determined that the facility failed to provide assistance with Activity of Daily Living (ADL) involving consistent shower or baths for five out of seven residents (Residents R3, R39, R57, R123, and R125). Findings include: The facility Activities of daily living policy dated 5/1/23, and last reviewed 7/18/23, indicated that activities of daily living include bathing, dressing, oral care, toileting, eating and functional communication. Documentation of ADL care is recorded in the medical record and is reflective of the care provided by nursing staff. ADL care is documented in real time. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/21/23, indicated diagnoses hypertension (high blood pressure), diabetes (high blood sugar levels), and hemiplegia (muscle…

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 resident clinical records, facility policy, and staff interviews, it was determined that the facility failed to provide consistent and complete communication with the dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for two of three residents (Residents R45 and R56), and failed to have physician orders for monitoring of access sites for one of three residents (Resident R25). Findings include: Review of facility policy Dialysis: Hemodialysis External Catheter and Maintenance dated 7/18/23, indicated the licensed nurse is responsible for evaluating and maintaining the external hemodialysis catheter site for patients with an external hemodialysis catheter. Review of the clinical record indicated Resident R25 was admitted to the facility on [DATE]. Review of Resident R25's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/16/23, indicated diagnoses of hypertension (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, nursing staff personnel records, nurse training documentation and staff interview, it was determined that the facility failed to ensure that nursing staff received annual in-service education for three out of six nursing personnel (Nurse Aide (NA) Employee E21, Licensed Practical Nurse (LPN) Employee E22, and Registered Nurse (RN) Employee E23). Findings include: The facility In-Service Training policy, dated 7/18/23, indicated that the facility will provide in-service training for all personnel on a regularly scheduled basis. All mandatory in-service requirements must be completed annually as a condition of continued employment. Training topics include effective communication, resident's rights, abuse, neglect, and exploitation, dementia management, infection control, compliance and ethics, quality assurance, and behavioral health. Review of NA Employee E21's personnel record indicated that she was hired to the facility on [DATE]. Review of NA Employee E21's personnel record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, facility documents, clinical record review and staff interview, it was determined that the facility failed to accurately assess residents for social services needs for three of nine residents (Resident R86, R138, and R153). Review of the facility Social Service Director job description indicated that responsibilities include to complete or ensure that patients, family, and staff interviews are conducted for completion of relevant Minimum Data Set (MDS -periodic assessment of care needs) sections (i.e. cognitive, mood, behavior, patient goal setting) and Care Area Assessments are completed in accordance with regulation. Review of facility policy Communications with Persons with Limited English Proficiency, dated 7/18/23, indicated that the facility will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in the services, activities, programs, and other benefits as provided by skilled 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident records, observations and staff interview it was determined that the facility failed to implement measures to prevent the potential for cross contamination during a dressing change for one of three residents (Resident R117), failed to utilize infection control precautions and prevent the potential for cross-contamination in a room with a COVID-19 positive resident (Resident R181), and failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for four of 12 months (February 2023, March 2023, May 2023, and December 2023), Findings include: Review of facility policy Wound Dressings dated 7/18/23, indicated that wound dressings are performed using aseptic (free from contamination) technique. The purpose is to decrease the risk of wound contamination and cross-contamination during dressing changes. The facility Special droplet and contact precautions policy dated 12/7/22 and last…

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, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to provide an environment that maintained and enhanced each resident's quality of life for one of eight residents (Resident R153). Findings include: Review of facility policy Communications with Persons with Limited English Proficiency, dated 7/18/23, indicated that the facility will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in the services, activities, programs, and other benefits as provided by skilled nursing facilities. The facility must provide language assistance through the use of external interpretation and translation services, technology and/or telephonic interpretation services. The facility shall not require an LEP person to provide his or her own interpreter. Some LEP persons may prefer or request a patient representative as an interpreter,…

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 make certain that a resident representative was informed, in advance, of changes to the plan of care and failed to ensure a resident representative was notified in advance of care conference meetings for two of three sampled residents (Resident R43 and Closed Resident Record CR166). Findings include: The facility Person-centered care plan policy dated 7/18/23, indicated that the facility has the responsibility to assist residents to participate by facilitating the inclusion of the resident or resident's representative to attend care plan meetings. The resident has the right to be informed in advance of changes to the plan of care. Review of Resident R43's admission record indicated she was originally admitted on [DATE]. Review of Resident R43's MDS assessment Minimum Data Set assessment (MDS- a periodic assessment of resident care needs) dated 12/2/23, indicated she had diagnoses that 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, notice of non-coverage documents, clinical record review and staff interview, it was determined that the facility failed to issue a Notice of Medicare Non-Coverage form published by the Centers for Medicare and Medicaid Services (NOMNC CMS-10123), for one of three residents (Resident R293). Findings include: Review of the facilities Managed Care NOMNC (Notice of Medicare Non-Coverage) Process, dated 7/18/23, indicated that the facility is responsible to issue the NOMNC timely to the resident, POA or designated person responsible for the resident for their signatures. Review of the clinical record indicated that Resident R293 was admitted to the facility on [DATE], and remained in the facility. A review of the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form CMS-20052 (published by the Centers for Medicare and Medicaid Services and used to determine if nursing care facilities are in compliance with notifying residents/resident representatives of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, facility submitted documents, incident reports, and staff interview, it was determined that the facility failed to provide services to create an environment free from neglect for one of four sampled residents (Resident R95). Findings include: The facility Abuse prohibition policy dated 2/23/21, and last reviewed on 7/18/23, indicated that the facility prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. Neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of Resident R95's originally admitted [DATE]. Review of Resident R95's Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 11/15/23, indicated he had diagnoses that included chronic congestive heart failure (a progressive heart disease affecting 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, newly hired personnel records and staff interviews it was determined that the facility failed to properly screen an employee by completing a State background check prior to hire for one out of five personnel records (Agency Dietary Aide Employee E20). Findings include: The facility Abuse prohibition policy dated 7/18/23, indicated that the facility will implement an abuse prohibition program by screening potential hires, training employees, and identifying possible incidents. The facility will screen potential employees for a history of abuse, neglect, or mistreating residents, including attempting to obtain information. Review of Agency Dietary Aide Employee E20's personnel record indicated she was hired 1/9/24. Review of Agency Dietary Aide Employee E20's personnel record did not include a State background check prior to the date of hire. During an interview on 1/9/24, at 11:05 a.m. Dietary Aide Employee E20 stated today is my first day. During an interview on 1/12/24, at 9:21 a.m. Human Resources/Scheduler Employee E2 confirmed that 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, clinical record review, investigation documentation, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out neglect and/or abuse for one of four sampled residents (Resident R123). Findings include: Review of facility policy Abuse Prohibition dated 8/17/23, indicated that neglect is defined as the failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will conduct an investigation that will be thoroughly documented. Review of facility policy Accidents/Incidents dated 8/17/23, indicated the licensed nurse will report accidents/incidents and assist with completion of a timely investigation to determine root cause. Employees witnessing an accident/incident involving a patient will communicate a factual description of his/her findings to the supervisor or the nurse responsible on the unit. The Administrator, DON, or designee will review all…

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 records, and staff interviews, it was determined that the facility failed develop and implement a base line care plan within 48 hours of the resident's admission that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for one of six residents (Resident R292) reviewed. Findings include: Review of facility policy Person-Centered Care Plan, dated 7/18/23, indicated that the facility must develop and implement a baseline person-centered care plan within 48 hours of admission/readmission for each patient/resident that includes the instruction needed to provide effective and person-centered care that meet professional standards of quality care. Review of Resident R292 clinical record indicated that she was admitted to the facility 12/31/23, with diagnoses that include diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as fuel), heart disease, and malignant neoplasm of cecum (cancer in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident records, and staff interview it was determined that the facility failed to identify a pressure ulcer during the admission evaluation for one of nine sampled residents with a pressure ulcer (Resident R175). Findings include: The facility Skin integrity and wound management policy last reviewed 7/18/23, indicated that an initial and ongoing nurse assessment of intrinsic and extrinsic factors that influence skin health, wound impairment, and the ability of the wound to heal will be performed. Complete a comprehensive evaluation of the resident upon admission and identify the resident's skin intergrity status. Review of Resident R175's admission record indicated she was admitted on [DATE]. Review of Resident R175's MDS assessment (Minimum Data Set assessment--MDS: a periodic assessment of resident care needs) dated 1/5/24, indicated she had diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body),…

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 records, facility documents and staff interview, it was determined that the facility failed to prevent injury during a shower, resulting in a fall that required transfer to the hospital for one of three residents sampled (Resident R123) and that the facility failed to ensure that a resident received neurological assessment after an incident involving a fall for two of three sampled residents (Closed Resident Record CR166). Findings include: Review of facility policy Accidents/Incidents dated 8/17/23, indicated an accident is defined as an unexpected or unintentional incident which occurred, or allegedly occurred, on or off Center property involving, or allegedly involving, a patient who is receiving services. The facility Falls management policy dated 8/7/23, indicated that a fall is unintentionally coming to rest on the ground. Residents experiencing a fall will receive appropriate care and post-fall interventions will be implemented. Any resident who has an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records and staff interviews, it was determined that the facility failed to monitor a resident's weight for one of five residents (Resident R45) Findings include: Review of the facility policy Weights and Height dated 7/18/23, indicated that patients are weighed upon admission and/or re-admission, then weekly for four weeks, and monthly thereafter, and that the purpose of obtaining weights is to identify significant weight change, and determine possible causes of significant weight change. Review of the clinical record revealed that Resident R45 was admitted to the facility on [DATE]. Review of Resident 45's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 12/4/23, indicated diagnoses of end stage renal disease (kidneys are severely damaged and are not working as well as they should to filter waste from blood), dementia ( a group of symptoms that affects memory, thinking, and interferes with daily life), and high blood pressure. Review of weight record for Resident R45…

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, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for three of five residents (Resident R13, R39, and R56). Findings include: Review of facility policy Oxygen: Nasal Cannula dated 7/18/23, indicated the facility will date and replace the entire set-up every seven days. Review of facility policy Nebulizer: Small Volume dated 7/18/23, indicated the facility will place equipment in a treatment bag labeled with patient name and date, and replace and date the set-up daily. Review of a facility Grievance/Concern form dated 10/9/23, indicated the facility received a concern that Resident R117's oxygen tubing was dated 9/28/23 and that the change was overdue. Review of the clinical record indicated that Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/14/23, indicated diagnoses of hypertension (high…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician responded timely pharmacy medication recommendations for two out of five sampled residents (Resident R39 and R92). Findings include: The facility Medication Regimen Review policy dated 8/17/23, indicated the consultant pharmacist will conduct Medication Regimen Review (MRR) and will make recommendations based on the information available in the resident's health record. If an irregularity does not require urgent action, it should be addressed before the consultant pharmacist's next monthly MRR. The facility should alert the Medical Director when MRR's are not addressed by the attending physician in a timely manner. Review of the clinical record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/2/23, indicated diagnoses of hypertension (high blood pressure),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to make certain a resident's medication regimen was free from potentially unnecessary medication for one of five sampled residents (Resident R39). Findings include: Review of facility policy Psychotropic Medication Use dated 8/17/23, indicated psychotropic drugs include but are not limited to antipsychotics, anti-anxiety, antidepressants, or sedative-hypnotics that affect brain activities associated with mental processes and behavior. the facility should comply with the Psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual, and all other Applicable Law relating to the use of Psychopharmacologic medications including gradual dose reductions. The facility Medication Regimen Review policy dated 8/17/23, indicated the consultant pharmacist will conduct Medication Regimen Review (MRR) and will make recommendations based on the information…

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, observations, and staff interviews it was determined that the facility failed to accurately label and date open medications for two sampled medication carts (Arcadia medication cart and Second floor medication cart number one), and failed to secure medications in two out of six medication carts (First floor Skilled Medication Carts One and Two), and failed to ensure that outdated biologicals were discarded in one of two medication rooms (LTC Unit) Findings include: The facility Storage, expiration, and dating of medications, biologicals dated [DATE], indicated that the facility should ensure that medication and biologicals are stored in an orderly manner in cabinets, drawers and carts. The facility should ensure that medication and biologicals are securely stored in a locked cabinet or locked medication room. The facility should ensure that medication and biologicals have an expired date on the label. Facility staff should record the date opened on the primary 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 review of facility documents, facility policy review, and staff interview, it was determined that the facility failed to ensure that all required staff persons were in attendance at quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for one of four quarters reviewed (second quarter, April - June 2023). Findings include: Review of the CFR (Code of Federal Regulations) §483.75(g) Quality assessment and assurance. §483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (iv) The infection Preventionist. (i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects…

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

Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for three of twelve months (February 2023, March 2023, and December 2023). Findings include: Review of facility policy Antibiotic Stewardship dated 7/18/23, indicated centers will implement an Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and systems for monitoring antibiotic use. Review of the facility's Infection Control surveillance for January 2023 through December 2023, failed to include documentation to indicate that antibiotic monitoring was completed for February 2023, March 2023, and December 2023. During an interview on 1/11/24, at 10:55 a.m. the Assistant Director of Nursing (ADON) confirmed that the facility was unable to locate and provide documentation to indicate that antibiotic monitoring was completed for February 2023, March 2023, and December 2023. During an interview on 1/11/24, at 10:55 a.m. the ADON confirmed that the facility failed to implement…

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 personnel records and staff interviews it was determined that the facility failed to provide newly hired staff with an orientation involving training for resident abuse and exploitation for one out of five personnel records (Agency Dietary Aide Employee E20). Findings include: The facility Abuse Prohibition policy last reviewed on 7/18/23, indicated that the facility prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. The Facility will implement an abuse prohibition program through training of employees, both new employees and ongoing training for all employees. Training and reporting obligations will be provided to all employees through orientation. Review of Agency Dietary Aide Employee E20's personnel record indicated she was hired 1/9/24. Review of Agency Dietary Aide Employee E20's personnel record did not include documentation for training on resident abuse and exploitation. During an interview on 1/12/24, at 9:25 a.m. Human Resources/Scheduler Employee E2 confirmed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical record review and staff interview, it was determined that the facility failed to timely provide the skilled nursing facility Notice of Medicare Non-coverage (NOMNC) form as required for one of five residents (Resident R1). Findings include: Review of Resident R1's admission record indicated that he was admitted on [DATE], with diagosis that included fracture of right lower leg,anemia and coronary artery disease (plaque buildup in the wall of the arteries that supply blood to the heart). Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment, periodic assessment of resident care needs) dated 10/25/23, indicated that the diagnoses remain current upon review. Review of Resident R1's Notice of Medicare Non-coverage (document indicating an end of skilled services) was provided on 10/27/23, his skilled services ended on 10/27/23. During an interview on 11/7/23, at 1:30 p.m. Social Worker Employee E1 and Director of Nursing confirmed that the facility failed to provide the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to administer medications as prescribed by the physician for one of five residents (Resident R2). Findings include: A review of the clinical record indicated Resident R2 was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (an irregular and often very rapid heart rhythm), hypothyroidism(thyroid gland doesn't make enough thyroid hormones to meet your body's needs) and anemia(condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells). A review of Resident R2's five day MDS assessment(minimum data assessment)- periodic assessment of resident care needs) dated 8/28/23, indicated the diagnosis remained current. A review of R2's physician orders dated 8/24/23, indicated Atenolol 25 mg 1 tablet a day for blood pressure give only for HR (heart rate) over 70 or BP (blood pressure) over 140/70. A review of Resident R2's pulse and blood pressure…

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 of representative concern, and resident and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties in the Main Kitchen. Findings include: The facility Mealtimes and Delivery policy dated June 2023, indicated that meals are provided at predictable times, three times daily, and that food is delivered promptly to designated locations. Review of Food Truck Delivery Times Schedule indicated the following delivery times and locations: Lunch is to be delivered to the TCC unit at 12:15 p.m. Dinner is to be delivered to the Grande 1 unit at 5:45 p.m. Dinner is to be delivered to the TCC unit at 6:15 p.m. Dinner is to be delivered to the Skilled unit at 6:25 p.m. Dinner is to be delivered to the Arcadia unit at 6:45 p. m. and 6:50 p.m. Review of a resident representative ' s concern stated that residents in the Arcadia unit do not receive dinner until 8:00 p.m. or 9 p.m. During an interview on 9/28/23, at 10:05 a.m., Resident R1, who resides on the Skilled unit, stated one day last week…

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, observation, and staff interview, it was determined that the facility failed to ensure confidentiality of personal health information for two of 11 residents (Resident R6, and R7). Findings include: Based on the facility 2023 Welcome Packet, provided to residents at admission, residents have the right to be informed, make their own decisions, and have personal information kept private. Review of clinical record revealed that Resident R6 was admitted to the facility on [DATE], with diagnoses that included malignant melanoma (a serious type of skin cancer), atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), and rib fractures. During an observation on 9/28/23, at 10:10 a.m., a sign was posted on Resident R6's bulletin board with a date and time of an upcoming appointment at the [NAME] Cancer Center. Review of clinical record revealed that Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's MDS (Minimum Data…

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

Based on observations, and staff interviews, it was determined that the facility failed to make certain that a resident environment remained free of potential accidents or hazards by padlocking a means of egress for one of eight units (Arcadia). Findings include: Review of Title 42 Code of Federal Regulations (CFR) §483.25(d)(1) indicated that a resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Review of facility policy titled Fire Drills, dated June 2023, indicated that residents will be able to evacuate the entire building to a public thoroughfare, or to a fire-safe area and within the period of time designated in writing within the past year by a fire safety expert. During an observation on 928/23 at 9;24 a.m. on the Arcadia Dementia unit, residents were gathered in the dining room eating breakfast. A door was noted in the dining room that led to an outside enclosed courtyard. The door was secured by a padlock. During an interview on 9/28/23, at 11:50…

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.