Southwestern Veterans Center

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 three of five residents (Residents R13, R31, and R51). Findings include: Review of facility policy Supplemental Oxygen Therapy dated 1/16/25, indicated used cannulas, masks, and tubing shall be stored in a plastic bag, off the floor, labeled with the Resident's name, when not in use. Review of facility policy Noninvasive Ventilation: BiPAP, CPAP dated 1/16/25, indicated when not in use, assembled headgear, masks, and tubing shall be stored in a plastic bag, labeled with the resident's name and date. Review of Resident R13's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/3/25, indicated the diagnoses of coronary artery disease (narrow arteries decreasing blood flow to heart), hypertension (the force of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to maintain complete and accurate documentation for five of eight residents (Residents R13, R16, R21, R91, and R104). Findings include: Review of the facility policy Permitted Charges for Medical Records dated 1/16/25, indicated the medical record is an accounting of events and interactions between an individual and a healthcare provider. Medical records assist in analyzing trends in healthcare use, an individual's characteristics and quality of care. Review of the facility job description Registered Nurse (RN) indicated the RN is to record daily care performed for the residents on the appropriate forms and the approved electronic medical record and establish and maintain effective communication with resident, family, and staff. Review of Resident R13's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs)…

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 accommodate the call bell needs for one of five residents (Resident R88). Findings include: Review of the clinical record indicated Resident R88 was admitted to the facility on [DATE]. Review of Resident R88's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/13/25, indicated diagnoses of hemiplegia (paralysis on one side of the body), anxiety, and constipation. During an observation on 4/21/25, at 12:18 p.m. Resident R88's call bell was observed on the floor under the resident's bed. During an interview on 4/21/25, at 12:19 p.m. Licensed Practical Nurse Employee E2 confirmed Resident R88's call bell was not accessible and unavailable for use to the resident and that the facility failed to accommodate Resident R88's call bell needs. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for two of six residents (Residents R51 and R113). Findings include: Review of facility policy MDS 3.0 Completion, Maintenance, and Submission dated 1/16/25, indicated all disciplines shall follow the guidelines in Chapter 3 of the current RAI Manual for coding each assessment. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated the following instructions: - Section O: Special Treatments, Procedures, and Programs - Question O0110C1, Oxygen therapy: Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to 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 policy, clinical records, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive care plan to meet care needs for two of eight residents (Residents R40 and R89). Findings include: Review of facility policy Comprehensive Care Plans last reviewed on 1/16/25, indicated that facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Review of the clinical record indicated Resident R40 was admitted to the facility on [DATE]. Review of Resident R40's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/3/25, indicated diagnoses of anemia (low levels of iron in the blood), high blood pressure, and Parkinson's Disease (neuromuscular disorder causing tremors and difficulty…

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 interviews with staff, it was determined that the facility failed to revise the comprehensive care plan to reflect resident's current needs for three of six residents (Residents R29, R85, and R88). Findings include: Review of facility policy Comprehensive Care Plans (Nursing Care) dated 1/16/25, indicated the care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the admission record indicated Resident R29 admitted to the facility on [DATE]. Review of Resident R29's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/20/25, indicated diagnoses of end stage renal disease (kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), hypertension (the force of the blood against the artery walls is too high), and diabetes (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 the review of facility job descriptions, clinical records, and staff interviews, it was determined that the facility failed to follow standards of professional practice for two of five residents (Residents R21 and R104). Findings include: Review of the facility job description Registered Nurse (RN) indicated the RN is to record daily care performed for the residents on the appropriate forms and the approved electronic medical record and establish and maintain effective communication with resident, family, and staff. Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE]. Review of Resident R21's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/6/25, indicated diagnoses of constipation, hypocalcemia (low levels of calcium in the blood), and Vitamin D deficiency. Review of a progress note dated 4/6/25, completed by RN Employee E16 stated, Resident continues to have menial tasks for staff that she requests one at a time. She first had RN go to her…

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 interviews with staff, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers for two of four residents (Residents R21 and R88) and failed to make certain that residents received the necessary services to prevent pressure ulcers/wounds from developing for one of four residents (Resident R133). Findings include: Review of the facility policy Management of Pressure Injuries dated 1/16/25, indicated the facility will use a standardized plan for defining, assessing, documenting, and implementing strategies for the prevention and treatment of pressure injuries on all residents. Braden Scale will be the instrument used to determine the potential or actual risk for pressure ulcers. Residents who score between 15-18 are at risk. Utilization of pressure relieving devices, including special mattresses, elbow, and heel protectors may be used. Residents with pressure ulcers shall receive…

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 record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of three residents. (Residents R33 and R104). Findings include: Review of the facility policy Pre and Post Dialysis dated 1/16/25, indicated prior to departing the unit for transfer to dialysis (the clinical purification of blood by dialysis as a substitute for the normal function of the kidney), the licensed staff will complete the Dialysis Communication Form with each transfer to the dialysis clinic. Upon return to the unit, the licensed staff will complete the return portion of the Dialysis Communication Form and file in the appropriate section of the chart. If no communication form is received, please call dialysis, and have one faxed to the facility. Review of the admission record indicated Resident R33 was admitted to the facility on [DATE]. Review of Resident R33'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, 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 two of four residents (Residents R7 and R51). Findings include: Review of facility policy Culturally Competent, Trauma Informed Care dated 1/16/25, indicated the purpose of this protocol is to provide guidance to the facility to guide staff in providing appropriate, culturally competent care to residents who have experienced a trauma and to safeguard re-traumatization by employing supportive services related to minimizing triggers. The facility will assess each resident for a history of trauma and cultural preferences, upon admission, annually and with significant change. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, discussing cultural needs and social history. 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 personnel records and staff interview it was determined that the facility failed to complete annual performance evaluation for one of three nurse aide (NA) personnel records (NA Employee E18). Findings include: Review of CFR (Code of Federal Regulations) §483.35(d)(7) Regular in-service education. The facility must complete a performance review of every nurse aide at least once every 12 months and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g). Review of NA Employee E18's personnel record indicated she was hired to the facility on 5/2/22. Review of personnel records did not include an annual performance evaluation based on the date of hire for NA Employee E18. Interview on 4/22/25, at 1:16 p.m. Human Resource's Employee E5 confirmed that the facility failed to complete annual performance evaluation based on date of hire for NA Employee E18. 28 Pa Code: 201.14 (b) Responsibility of licensee 28 Pa Code: 201.18 (b)(1)(3) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to maintain proper infection control practices related to the care of indwelling urinary catheters (tube inserted in the bladder to drain urine) for one of three residents reviewed (Residents R107). Findings include: Review of facility policy Urinary Catheter Procedures dated 1/16/25, indicated the purpose is to promote a healthy urinary tract, promote continence, and to maintain healthy skin integrity. To achieve free flow of urine the collection bags, tubing is never to touch the floor. Review or facility policy Infection Control Plan dated 1/16/25, indicated policy is to maintain a consistent, comprehensive approach to the prevention and management of infections. The goal of the program is to provide a safe and sanitary environment, decrease the risk of infection to residents, and correct problems relating to infection control practices. Review of Resident R107's clinical record indicated 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 observations and resident and staff interviews, it was it was determined that the facility failed to obtain physician's orders for five of seven residents (Resident R25, R88, R89, R90, and R94) failed to develop comprehensive care plans to meet resident care needs for three of five resident records (Residents R88, R89, and R90) and failed to complete a bed safety risk assessment for three of four resident (R88, R89, and R90). Findings Include: Review of facility policy Simple Dressing Change last reviewed 4/19/24, indicated to clean wound with normal saline or prescribed cleanser. Follow procedure for wound cleansing/irrigation. Review of facility policy Wound Care last reviewed 4/19/24, indicated the implementation of medication procedures according to physician orders and established facility guidelines to ensure the standards of resident care are delivered in wound therapy. Review of facility policy Bed Entrapment Zone Inspection last reviewed 4/19/24, indicated entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed…

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 provide access to medical records to a resident or representative within a 24 hour period and/or to provide copies of medical records to the resident or representative within 48 hours for one of three residents (Resident R202). Findings include: Review of facility documents indicated that a request for a copy of medical records by a representative of Resident R202 was received on 11/21/23 and was never sent. During an interview on 5/8/24, at 1:15 p.m. Medical Records Employee E2 stated that she received the signed request from Resident R202's representative on 11/21/23, but did not send them, she misunderstood the regulation. 28 Pa. Code 201.29(a) Resident rights.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and interviews with staff, it was determined that the facility failed to revise the comprehensive care plan after a diet update for one of four residents (Resident R119). Findings include: A review of facility policy Support Plans/Comprehensive Care reviewed 4/19/24 , indicated it shall be revised within 30 days upon completion of the annual assessment or upon changes in the resident's needs as indicated on the current assessment. A review of the clinical record indicated Resident R119 was admitted to the facility on [DATE], with diagnoses that included chronic atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), malaise and dry eye syndrome. A review of the Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) dated 2/12/24, indicated the diagnosis remained current. A review of resident physician's orders dated 4/9/24 indicated that Resident R119s tube feeding was discontinued. 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 observation, clinical record review and staff interview, it was determined that the facility failed to provide treatment and services to prevent further decrease in range of motion for two of four residents (Residents R2 and R25). Findings include: Review of Title 42 Code of Federal Regulations (CFR) §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Interview with the Director of Nursing on 5/8/24, at 1:25 p.m. indicated the facility does not have a policy on assistive devices or palm guards (a splint for the hand). Review of the admission record indicated Resident R2 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS- a periodic assessment of care needs) dated 4/18/24, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), peripheral vascular disease (a condition 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, clinical records, incident reports and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of three residents (Resident R140) and resulted in a cat bite for two of three residents (Residents R14 and R119). Findings include: Review of the facility policy Incidents and Accidents dated 4/19/24, indicated the protocol is to provide guidance to assist with maintaining the Residents' safety and prevention of serious injury to the extent possible. Root Cause Analysis (RCA) is a method of problem solving used for identifying the root cause of faults or problems. It includes the process of learning from consequences wherein healthcare providers take a step back and gain knowledge from near misses, or adverse events to prevent recurrence. Review of the facility policy Wandering/Elopement…

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 interview, it was determined the facility failed to provide consistent, and complete communication with the dialysis center for three of three residents reviewed (Residents R35, R81, and R106), and failed to have accurate physician orders and care plan for one of three residents reviewed (Resident R106). Findings include: Review of the facility policy Pre and Post Dialysis dated 4/19/24, indicated prior to departing the unit for transfer to dialysis (the clinical purification of blood by dialysis as a substitute for the normal function of the kidney), the licensed staff will complete the Dialysis Communication Form with each transfer to the dialysis clinic. Upon return to the unit, the licensed staff will complete the return portion of the Dialysis Communication Form and file in the appropriate section of the chart. If no communication form is received, please call dialysis, and have one faxed to the facility. Check thrill by palpating 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 Review of facility documentation and interviews with staff determined that the facility failed to have enough staff to meet residents needs for one of three residents reviewed (Resident R1). Findings include: Review of Resident R1's admission record indicated he/she was admitted on [DATE]. Review of Resident R1's MDS (minimum data set - a brief periodical assessment of resident needs) dated 11/16/23, indicated diagnosis of psychotic disorder with delusions (presence of one or more delusions- psychosis lost touch with reality), repeated falls , and unspecified dementia with behavioral disturbances (dementia affects your thinking, memory, reasoning, personality, mood and behavior with behavioral disturbances). Review of Resident R1 care plan initiated 11/6/23, revealed Resident R1 problem resident is at risk for falls with the goal of remain injury free, and the approach was to have staff supervison 1:1 due to high fall risk and frequent falls. Review of the clinical record failed to include further documentation…

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

Based on review of job descriptions, facility documents and staff interviews, it was determined that the Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to make certain that the residents were protected from neglect in the facility which placed the residents in Immediate Jeopardy situations. Findings include: Review of job description Veterans Extended Care Facility Commandant (Nursing Home Administrator/NHA) last dated 2/1/22, stated The employee in this position is responsible for managing, directing and controlling all health - care activities and management functions at the Southwestern Veterans Center (SWVC), Department of Military and Veterans Affairs (DMVA). The facility provides nursing, personal and Domiciliary care, treatment, and restorative and rehabilitative services for veterans requiring long - term care. Direct and coordinate administrative functions with therapeutic functions to support resident care and treatment. Develop and maintain, with input from staff managers and department heads, written policies to…

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

Based on a review of facility policies, documents, resident council minutes and staff interviews it was determined that the facility failed to implement the grievance process in accordance with Federal regulations for one of one resident concern (Resident R1) and for three of three months of resident concerns voiced during resident council meetings (8/23, 9/23, and 10/23). Findings include: A review of facility policy Resident Grievance Process last reviewed 5/17/23, indicated that the facility has a standardized system to resolve resident grievances in a timely manner. The facility will ensure conformity to Federal and State regulations for resident rights. The facility will guarantee all residents have the Right to complain, including the right to: present grievances to the staff of the facility, or any other person without fear of reprisal, prompt efforts by the facility to resolve grievances, and register a complaint with the survey agency and or local ombudsman. A review of the facility's grievance log and resident council minutes including concern resolutions failed to provide…

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

Based on a review of facility policies, documents, facility provided documents of incidents and staff interviews it was determined that the facility failed to report allegations of resident abuse to the state agencies in a timely manner for two of two reporting opportunities. (11/3/23, and 11/4/23) Finding include: A review of facility policy Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property last reviewed on 5/17/23, indicated in Section 3 Reporting of alleged violations number 4 the facility will ensure that each covered individual shall report immediately the suspicion, A review of of the State Agency's facility provide documents dated 11/6/23, revealed that the facility reported two alleged abuse incidents that occurred on 11/3/23. A review of Nurse Aide Employee E 1's (NA) Due Process Conference documents date 11/15/23, it was revealed that NA Employee E1 notified the Director of Nursing on Saturday 11/4/23, of two alleged incidents of resident abuse that occurred on Friday 11/3/23. At this time, NA Employee E1 was instructed to report 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 a review of clinical records, observations and resident and staff interviews it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to provide requested sleeping arrangements for two of two residents. (Resident R1 and Resident R2) Findings include: Review of Resident R1's clinical records indicated that Resident R1 was admitted to the facility on [DATE], with the following diagnosis: rheumatoid arthritis (a chronic inflammatory disease affecting many joints, including those in the hands and feet), high blood pressure, intercostal pain - left lateral ribs (symptoms include tightness of the muscle, pain usually occurs with movement), abnormal posture - postural instability of trunk trunk control impairment) , age related osteoporosis without current fracture, insomnia Review of Resident R2's clinical records indicated that Resident R2 was admitted to the facility on [DATE], with the following diagnosis: mild cognitive…

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