Spring Hill Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, documentation, and staff interviews it was determined that the facility failed to protect residents from neglect for two of three residents (Resident R4 and R8). Findings include: Review of facility's policy dated 6/1/25, Abuse, Neglect, and Exploitation stated neglect is the failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. It is indicated it is the policy of the facility that each resident will be free from abuse. Review of Residents R4's admission record indicated the resident was admitted on [DATE], and readmitted [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/2/26, indicated diagnoses of cognitive communication deficit, dysphagia (difficulty swallowing), and depression. Section GG- Functional Abilities revealed the resident is dependent for toileting hygiene. 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 update the care plan for a resident experiencing weight loss one of five sampled residents (Resident R30).Findings include: The facility Weight monitoring policy last reviewed on 5/1/26, indicated that the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns. The care plan should address the following: identified causes of impairment, residents' goals and preferences, time frame and parameters to monitor, and update as needed such as when resident's condition changes. Review of Resident R30's admission record indicated she was admitted on [DATE] and readmitted on [DATE]. Review of 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.

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 implement care and services to maintain activities of daily living (communication) for two of three residents reviewed (Resident R4 and R44).Findings include: Review of the facility's Activities of Daily Living (ADLs) policy last reviewed 5/1/26, indicated the facility will based on resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless unavoidable. Care and services will be provided for using speech, language or other functional communication systems. Review of the facility's Communication of Resident Rights, Services, and Facility Practices last reviewed 5/1/26, indicated it the facility policy to promote transparency, protect resident rights, and ensure residents can make informed decisions regarding their care and living environment. Information must be provided in a language and manner the resident understands,…

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 council group interview, staff and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of five sampled residents (Resident R28).Findings include: The facility Activities of Daily living policy dated 5/1/26, indicated that the facility will ensure resident abilities in ADL's do not deteriorate. Care and services will be provided for the following activities of daily living: bathing, dressing, grooming and oral care. Review of Resident R28's admission record indicated she was admitted on [DATE] and readmitted on [DATE]. Review of Resident R28's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 4/21/26, indicated she had medical diagnoses that included anemia (a deficiency in red blood cells carrying oxygen), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and adult failure 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 the review of facility policy, clinical records, observation, and interviews with staff and resident, it was determined that the facility failed to make certain that residents received the necessary services to prevent/treat pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure to the skin) for two of three residents (Residents R3 and R11) and failed to follow a physician order during a dressing change observation for one of three residents (Resident R56). Findings include: Review of the facility policy Pressure Injury Prevention and Management dated 5/1/26, indicated that the facility will provide treatment and services to heal the pressure ulcer/injury, prevent infection, and the development of additional pressure ulcers/injuries. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic care interventions can include but are not limited to: redistribute pressure (such…

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 provide supervision with meals to monitor for signs and symptoms of dysphagia and failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for two of six residents (Residents R1 and Resident R8).Findings include: Review of facility policy Incidents and Accidents dated 5/1/26, indicated choking is an incident/accident. It is the facility policy to assure that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1 MDS (minimum data set - a periodic assessment of care needs), dated 3/13/26, indicated diagnosis of intellectual disabilities, esophageal varices, and GERD(Gastroesophageal reflux disease…

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, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (G- Tube, a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for two of two residents (Residents R3, and R4). Findings include: Review of the facility policy Care and Treatment of Feeding Tubes last reviewed 5/1/26, indicated it is the facility policy to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Feeding tubes will be utilized according to physician orders. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE], with the diagnoses of aphasia (language disorder that affects communication), hemiplegia (paralysis on one side of the body), and diabetes (a metabolic disorder in which the body has high sugar…

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, staff interview, and observations, it was determined that the facility failed to provide appropriate respiratory care for one of two residents (R8). Findings Include: Review of facility policy Oxygen Administration dated 5/1/26, indicated oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. The resident's care plan shall identify the interventions for oxygen therapy, based upon assessment and orders. Review of facility policy Comprehensive Care Plans dated 3/16/26, indicated the facility will develop and implement a comprehensive person-centered care plan for each resident. Review of Residents R8's admission record indicated the resident was admitted on [DATE], and readmitted [DATE], with indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), respiratory failure,…

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 provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents (Resident R1 and R33). Findings include: Review of facility policy Trauma Informed Care dated 5/1/26, indicated that the facility will identify triggers which may re-traumatize residents with a history of trauma and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1 MDS (minimum data set - a periodic assessment of care needs), dated 3/13/26, indicated diagnosis of PTSD (a mental health condition that caused by an extremely stressful or terrifying event), depression, and dysphagia (difficulty swallowing). Review of Resident R1's care plan dated 5/19/25, revealed the 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, personnel records and staff interviews, it was determined that the facility failed to complete annual performance evaluations for two of three nursing staff (Nurse Aide (NA) Employees E2 and E3).Findings include: Review of facility Evaluations Process policy last reviewed 5/1/26, indicated it is the policy of our facility to review the work performance of employees with a written evaluation yearly. Review of NA Employee E2's personnel record indicated a hire date of 3/12/24. Review of NA Employee E2's current employee file failed to reveal an annual employee performance evaluation for 3/12/25, through 3/12/26. Review of NA Employee E3's personnel record indicated a hire date of 4/5/24. Review of NA Employee E3's current employee file failed to reveal an annual employee performance evaluation for 4/5/25, through 4/5/26. During an interview completed on 4/19/26, at 1:50 p.m. Human Resource Employee E9 stated, I just started in February 2026, I am starting to use a new process and confirmed that the facility failed to complete annual performance…

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 develop and implement individualized person-centered care plans to address dementia for one of three residents reviewed (Resident R42).Findings include: Review of the clinical record revealed Resident R42 was admitted to the facility on [DATE]. Review of Resident R42's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/26, indicated diagnoses of high blood pressure, chronic pain, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident R42's care plan failed to indicate the facility had developed and implemented an individualized person-centered care plan to address Resident R42's dementia and cognitive loss. During an interview on 5/20/26, at 1:50 p.m. the Director of Nursing confirmed that the facility failed to develop and implement individualized person-centered care plans to address dementia for one of three residents reviewed…

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, clinical record review, and resident and staff interview it was determined that the facility failed to provide medically related social services to one of four residents (Resident R29).Findings include: Review of the facility Social Service policy dated 5/1/26, revealed the facility will provide medically-related social services to each resident, to assist in attaining or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. Review of Residents R29's admission record indicated the resident was admitted on [DATE]. Review of a social service progress note dated 2/12/26, revealed the resident decided he would like to pursue assisted living, Social Services continues to follow. Review of Resident R29's Minimum Data Set (MDS -a periodic assessment of resident care needs) dated 3/26/26, included diagnoses of indicated diagnoses of adult failure to thrive, muscle wasting, and glaucoma. Section B1000. Vision indicated the resident is severely…

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, resident interview, and staff interview it was determined that the facility failed to ensure that the pharmacy provided medications timely for one of eight residents reviewed (Resident R46).Findings include: Review of the facility policy Pharmacy Services dated 5/1/26, indicated that the facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. Review of the clinical record indicated Resident R46 was admitted to the facility on [DATE]. Review of Resident R46's MDS dated [DATE], indicated diagnoses of high blood pressure, chronic pain, and muscle weakness. During an interview on 5/17/26, at 10:42 a.m. Resident R46 stated that she has not received morphine (medication for severe pain) in the past…

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 interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician for one of four residents (Residents R11). Findings include: Review of facility policy Pharmacy Services dated 5/1/26, indicated it is the facility policy to ensure that pharmaceutical services, whether employed by the facility or under an agreement are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE], with diagnoses of Alzheimer's disease with late onset, schizoaffective disorder, and major depressive disorder. Review of Resident R11's care plan dated 11/9/22, indicated to consult with pharmacy, medical doctor, and psych to consider dosage reduction when clinically appropriate. Review of Resident R11's…

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, staff interview and observation it was determined that the facility failed to prime an insulin pen prior to administration for one of three residents (R55).Findings include: Review of the facility policy Insulin Pen last reviewed 5/1/26, indicated it is the policy of this facility to use insulin pens to improve the accuracy of insulin dosing. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. Prime the insulin pen by dialing up 2 units by turning the dose selector clockwise. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not repeat until at least one drop appears. Review of the clinical record revealed Resident R55 was admitted to the facility on [DATE]. Review of Resident R55's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/16/26, indicated diagnosis of hypertension (high blood pressure) and diabetes…

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 properly secure a treatment cart while not in use for two of two treatment carts (First Floor Treatment Cart and Second Floor Treatment Cart), failed to properly store medications in one of two medication storage rooms (First Floor Medication Room) and failed to properly store medications in two of four medication carts (First Floor East Hall Medication Cart and Second Floor [NAME] Hall Medication Cart).Findings include: Review of the facility policy Medication Storage last reviewed 5/1/26, indicated it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufactures recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. All drugs and biological will be stored in locked compartments. During a medication pass,…

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, facility menu, resident interviews, and staff interviews it was determined that the facility failed to follow the displayed menu for two of five observed meals (lunch meal 5/17/26, and lunch meal 5/18/26).Findings include: Review of posted lunch menu for 5/17/26, revealed that the entree was an egg salad sandwich on a croissant. During an observation on 5/17/26, at 12:50 p.m. in Frist Floor Lounge area, Resident R21 was served her lunch and upon inspecting her meal replied Look at these fancy croissants. and pointed to the plain hamburger bun that was served. During an interview on 5/17/26, at 12:57 p.m. Dietary Manager Employee E14 stated that the facility did not have croissants, and confirmed that the facility failed to serve the planned menu. Review of lunch menu for 5/18/26, revealed that Mechanical Soft (diet that is chopped to ensure ease in chewing) menu is to be served green beans. During an observation on 5/18/26, at 12:25 p.m. Resident R1 was served a Mechanical Soft diet, but received a chopped salad instead of green beans. During an interview 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.

Based on observations, and staff interviews it was determined that the facility failed to provide residents food products based on their preferences for one out of five residents (Resident R1).Findings include: During an observation on 5/18/26, at 12:25 p.m. Resident R1's lunch ticket indicated that he is to receive double portions, however, only a single portion of food was served. During an interview on 5/18/26, at 12:29 p.m. Nurse Aide Employee E23 confirmed that the facility failed to provide double portions per resident preference. Pa Code: 201.14(a) Responsibility of licensee.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for one of two residents (Resident R25).Findings include: Review of the clinical record revealed that 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 2/3/26, indicated diagnoses of high blood pressure, chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and muscle spasm. Review of physician order dated 10/29/25, indicated Resident R25 was admitted under hospice services. Review of Resident R25's current comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to include contact information for the hospice agency and how to access 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 Quality Assurance Attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly (August 2025 and April 2026) Findings include: A review of the QAA Committee meeting sign in sheets for 2025 indicated one meeting in August of 2025. A review of the QAA Committee meeting sign in sheets for 2026 indicated one meeting in April of 2026. During an interview on 5/21/26, at 1:09 p.m. Nursing Home Administrator confirmed that the facility failed to conduct QAA meetings at least quarterly with all of the required committee members as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (e ) (1)(2)(3)(4) Management

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 utilize appropriate Personal Protective Equipment (PPE) for one of three residents in reverse isolation precautions (Resident R57) failed to prevent cross contamination during a dressing change for one of three residents (Resident R56) and failed to prevent cross contamination during medication administration for one of three residents (Resident R18). Findings include: Review of the facility policy Dressings, Dry/Clean last reviewed 5/1/26, indicated the purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Verify that there is a physician order for this procedure. Steps in the procedure include but not inclusive to establish a clean field, discard disposable items into the designated contains, clean the bedside stand. Review of the facility policy Modified Protective Environment Precaution last reviewed 5/1/26, indicated place…

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 interview it was determined that the facility failed to maintain a fully functioning resident call bell system for one of two nursing units (second floor nursing unit).Findings include: During an observation on the second floor nursing unit the following was observed/heard: 5/17/26: 12:41 p.m. call bell ringing on second floor nursing unit, residents rooms call bell lights were not lit.5/18/26: 10:24 a.m. call bell ringing on second floor nursing unit, residents rooms call bell lights were not lit.5/19/26: 2:02 p.m. call bell ringing on second floor nursing unit, residents rooms call bell lights were not lit. During interviews on 5/17/26, 5/18/26 and 5/19/26 (Nurse Aide Employee E35,E36,and E37) indicated that the call bell system has been sounding for a while - and that there is no light for any room but the sound continuality goes off. We have to keep looking at the call light board or down the hallways. During an interview on 5/19/26: 2:03 p.m. Employee E38 Maintenance Director indicated that system is ringing consistently, all the call bells work…

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, policy review, and staff interviews, it was determined that the facility failed to ensure that its corridors were equipped with firmly secured handrails for one of two nursing floors (1st floor). Findings Include: An observation in the first floor nursing unit on 5/17/26, at 12:48 p.m. revealed that the handrail affixed on the front side of the nursing station was loose to touch. An interview with the housekeeper, Employee E36 on 5/17/26, confirmed the handrail was not secured properly. It was indicated he had been aware since Thursday and was unsure if maintenance was aware. An interview with the Registered Nurse Supervisor, Employee E28, on 5/17/26, at 12:55 p.m. confirmed that the handrails should be securely affixed to the walls. 28 Pa. Code 201.18 (b) (1) Management

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide annual training on Effective Communication for two of three staff members (Nurse Aide (NA) Employees E2 and E3).Findings include: Review of facility policy Continuing Education last reviewed 5/1/26, indicated compliance with the facilities standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of the facilities training program. Review of the facility policy Training Requirements- Communication Training last reviewed 5/1/26, indicated the facility will include effective communication as mandatory training for direct care staff. Review of NA Employee E2's personnel record indicated a hire date of 3/12/24. Review of NA Employee E2's current personal file failed to reveal annual in-service training on Effective Communication 3/12/25, through 3/12/26. Review of NA Employee E3's personnel record indicated a hire date of 4/15/24. Review of NA Employee E3's…

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 in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for one of three staff members Nurse Aid (NA) Employee E3.Findings include: Review of facility policy Continuing Education last reviewed 5/1/26, indicated compliance with the facilities standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of the facilities training program. Review of the facility policy Training Requirements- Abuse, Neglect and Exploitation Training last reviewed 5/1/26, indicated the facility will include activities that constitute abuse, neglect, exploitation, and misappropriation of resident property. Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident's property, dementia management and resident abuse prevention. Review of NA Employee E3's personnel record indicated a hire date of 4/5/24. Review of NA Employee E3's current personal file…

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 in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for one of three staff members (Nurse Aide (NA) Employee E3).Findings include: Review of facility policy Continuing Education last reviewed 5/1/26, indicated compliance with the facilities standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of the facilities training program. Review of the facility policy Training Requirements-Abuse, Neglect and Exploitation Training last reviewed 5/1/26, indicated the facility will include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facilities QAPI program. Review of NA Employee E3's personnel record indicated a hire date of 4/5/24. Review of NA Employee E3's current personal file failed to reveal annual in-service training on QAPI 4/5/25, through 4/5/26. During an interview completed…

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 in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Infection Control for one of three staff members (Nurse Aide (NA) Employee E3).Findings include: Review of facility policy Continuing Education last reviewed 5/1/26, indicated compliance with the facilities standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of the facilities training program. Review of the facility policy Training Requirements-Infection Control Training last reviewed 5/1/26, indicated that the facility will include a mandatory in-service training of its infection control program. Review of NA Employee E3's personnel record indicated a hire date of 4/5/24. Review of NA Employee E3's current personal file failed to reveal annual in-service training on Infection Control 4/5/25, through 4/5/26. During an interview completed on 4/19/26, at 1:50 p.m. Human Resource Employee E9 confirmed that the facility 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 review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Compliance and Ethics for one of three staff members (Nurse Aide (NA) Employee E3).Findings include: Review of facility policy Continuing Education last reviewed 5/1/26, indicated compliance with the facilities standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of the facilities training program. Review of the facility policy Training Requirements-Compliance and Ethics Committee Training last reviewed 5/1/26, indicated that the facility must include annual training of the compliance and ethics program. Review of NA Employee E3's personnel record indicated a hire date of 4/5/24. Review of NA Employee E3's current personal file failed to reveal annual in-service training on Compliance and Ethics 4/5/25, through 4/5/26. During an interview completed on 4/19/26, at 1:50 p.m. Human Resource Employee E9 confirmed that the facility failed 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 review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to ensure that two of three sampled Nurse Aides received a minimum of 12 hours of in-service education per year (NA Employee's E2 and E3).Findings include: Review of facility policy Continuing Education last reviewed 5/1/26, indicated compliance with the facilities standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of the facilities training program. Review of the facility policy Training Requirements-Required In-service Training for Nurse Aides last reviewed 5/1/26, indicated required in-service training for nurse aides will be sufficient to ensure the continuing competence of nurse aides but be no less that 12 hours per year. Review of NA Employee E2's personnel record indicated a hire date of 3/12/24. Review of NA Employee E2's current employee file failed to reveal that NA Employee E2 had received a minimum of 12 hours of yearly in-service training for…

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

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Behavioral Health for two of three staff members (Nurse Aide (NA) Employee E2 and NA Employee E3).Findings include: Review of facility policy Continuing Education last reviewed 5/1/26, indicated compliance with the facilities standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of the facilities training program. Review of the facility policy Training Requirements-Behavioral Health Training last reviewed 5/1/26, indicated that the facility will provide Behavioral Health training. Review of NA Employee E2's personnel record indicated a hire date of 3/12/24. Review of NA Employee E2's current employee file failed to reveal that NA Employee E2 had received Behavioral Health training for 3/12/25, through 3/12/26. Review of NA Employee E3's personnel record indicated a hire date of 4/5/24. Review of NA Employee E3's current employee file failed…

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 make certain that the necessary resident information was communicated to the receiving health care provider for one of three residents sampled with facility-initiated transfers (Residents R5) and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for two of three resident hospital transfers (Residents R5 and R6).Findings include: Review of facility policy Transfer or Discharge last reviewed 3/28/26, for transfer to another provider, for any reason, the following information must be provided to the receiving provider including but not inclusive of:Contact information of the practitioner who was responsible for the care of the resident.Resident representative information, including contact information.Advance directive information.All other 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.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in three of four medication carts (first floor East Medication Cart, first floor [NAME] Medication Cart and second floor [NAME] Medication Cart).Findings include: Review of the facility policy Medication Storage last reviewed 3/26/26, indicated all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. During an observation completed on 4/1/26, at 11:30 a.m. the first-floor [NAME] Medication Cart contained the following: Two Lispro insulin pens not stored in a bag as required. During an interview completed on 4/1/26, at 11:35 a.m. Licensed Practical Nurse (LPN) Employee E7 confirmed the two Lispro insulin pens were not stored in a bag as required During an observation completed on 4/1/26, at 11:42 a.m. the first-floor East 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, review of clinical records, resident interviews, and staff interviews, it was determined that the facility failed to ensure that residents are free from misappropriation of property for five of seven residents (Resident R1, R2, R3, R4, and R5). Findings include: Review of the facility policy Abuse, Neglect, &; Exploitation dated 9/22/25, indicated the facility will protect the health and welfare and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. Misappropriation of resident property is defined as the deliberate misplacement, exploitation or wrongful use or a resident's belongings or money without the resident's consent. Review of the facility policy Medication Ordering and Receiving from Pharmacy dated 9/22/25, indicated medication classification as controlled substances by state law, are subject to special ordering, receipt, and recordkeeping…

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 allegations of misappropriation of resident belongings for five of seven residents (Resident R1, R2, R3, R4, and R5). Findings include: Review of the facility policy Abuse, Neglect, &; Exploitation dated 9/22/25, indicated the facility will protect the health and welfare and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. Misappropriation of resident property is defined as the deliberate misplacement, exploitation or wrongful use or a resident's belongings or money without the resident's consent. Review of the facility policy Medication Ordering and Receiving from Pharmacy dated 9/22/25, indicated medication classification as controlled substances by state law, are subject to special ordering, receipt, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation for allegations of misappropriation of resident belongings for five of seven residents (Resident R1, R2, R3, R4, and R5). Findings include: Review of the facility policy Abuse, Neglect, &; Exploitation dated 9/22/25, indicated the facility will protect the health and welfare and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. Misappropriation of resident property is defined as the deliberate misplacement, exploitation or wrongful use or a resident's belongings or money without the resident's consent. Review of the facility policy Medication Ordering and Receiving from Pharmacy dated 9/22/25, indicated medication classification as controlled substances by state law, are subject to special ordering, receipt, 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 job description, clinical records, observations, and staff interviews, it was determined that the Director of Nursing (DON) failed to timely and effectively manage five allegations of misappropriation of resident belongings that included narcotic diversion for five of five residents (Resident R1, R2, R3, R4, and R5). Findings include: The job description for the Director of Nursing dated 12/9/24, indicated the DON is to plan, organize, develop, and direct the overall operations of the nursing service department. Establish facility policies and procedures and provide appropriate care and services to the residents. Plans, develops, organizes, implements, evaluates, and directs the overall operations of the nursing services department. Ensures delivery of compassionate quality care and nursing supervision as evidenced by adequate staff coverage on the units. Performs rounds to observe residents and ensure nursing needs are being met. Monitors for allegations of potential abuse or neglect and participate in the investigative process. Based on findings identified, 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 facility policy, observations, and resident interviews, it was determined that the facility failed to ensure that residents rights were maintained in having beds in working order for residents to maintain the highest level of functioning for one of two residents (Resident R1).Findings include: Review of the Resident Rights policy dated 9/22/25, indicated the facility will inform the resident of his or her resident rights during the stay in the facility. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely. Review of Resident R1's admission record indicated she was admitted to the facility on [DATE]. Review of the Resident R1's Minimum Data Set (MDS- periodic assessment of resident care needs) dated 1/10/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (a progressive heart disease 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.

Based on reviews of facility policy, employee files, facility documentation, and staff interviews, it was determined that the facility failed to verify current, valid license from licensing and registration boards to verify any disciplinary actions prior to employment for one of two employees (Registered Nurse Employee E1). Findings include: Review of facility policy Abuse, Neglect, and Exploitation reviewed 9/22/25, indicated that the facility will protect the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit ad prevent abuse, neglect, exploitation, and misappropriation of resident property. A potential employee will be screened for a history of abuse, neglect, exploitation, and misappropriation of residential property. Screenings may be conducted by the facility. The facility will maintain documentation of proof that the screening occurred. Review of facility policy Licensed Nurse Credentialing and License Verification reviewed 9/22/25, indicated all licensed nurses will have their credentials and license…

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, resident interview, and staff interview it was determined that the facility failed to ensure that the pharmacy provided medications timely for one of two residents reviewed (Resident R1).Findings include: Review of the facility policy Medication Ordering and Receiving from Pharmacy dated 9/22/25, indicated medications are administered in an organized and safe manner. Pour the correct number of tablets or capsules into the medication cup. Administer medication and remain with resident while medication is swallowed. Review of Resident R1's admission record indicated she was admitted to the facility on [DATE]. Review of the Resident R1's Minimum Data Set (MDS- periodic assessment of resident care needs) dated 1/10/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression. During 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.

Based on a review of facility documents and interviews with staff it was determined that the facility failed to provide the State Agency with access to facility investigation, causing a delay in the survey process. Findings include: During a complaint survey on 2/25/26, at 9:00 a.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware that the state agency (SA) team will be investigating five complaints. During an interview on 2/25/26, at 2:30 p.m. the SA was made aware that a nurse over the weekend was taking narcotics and that the police were notified. During an interview on 2/25/26, at 3:15 p.m. the Director of Nursing confirmed that a nurse had taken narcotics and that the police were notified on 2/22/26. The SA asked the DON for the facility's complete investigation for the incident to review. The DON stated, The investigation is in my office, I can go get it for you. The SA requested a copy of the full investigation at this time. During an interview on 2/25/26, at 3:55 p.m. the Interim Assistant Director of Nursing was made aware that SA was…

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

Based on review of facility documentation and staff and resident interviews, it was determined that the facility failed to maintain the facilities elevator (Main elevator) in safe operating condition for 11 of 11 days (January 6, 2026, through January 14, 2026).Findings include:The facility Elevator Use and Out-of-Service policy dated 9/22/25, indicated this policy is to ensure the safe and efficient use of the elevator at facility, maintain accessibility for residents and staff, and provide clear procedures when the elevator is out of service. This policy applies to all staff, residents, visitors, contractors, and vendors in the facility.Upon entrance to the facility on 1/14/26, at 9:00 a.m. the elevator on the Main floor was not functional and had a sign that stated, Do not use.During a review of facility provided documentation on 1/14/26, at 9:30 a.m. revealed on 1/6/26, Nursing Home Administrator (NHA) was notified by Plant Ops Director that the elevator was not functioning. Elevator service call was placed and came to facility same day. There was no disruption to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, resident interviews, and staff interviews, it was determined that the facility failed to accommodate the needs for four of five residents (Residents R1, R13, R14, and R18). Findings include:Review of facility policy Accommodation of Needs dated 9/22/25, indicated the facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident. Based on individual needs and preferences, the facility will assist the residents in maintaining and achieving independent functioning, dignity, and well-being to the extent possible.Upon entrance to the facility on 1/14/26, at 9:00 a.m. the elevator on the Main floor was not functional and had a sign that stated, Do not use.During an interview on 1/14/26, at 9:45 Maintenance Director Employee E12 stated, If a resident is on the second floor they would need to stay on the second floor. Our only elevator has been broken since 1/6/26,…

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

Based on review of personnel records and staff interview, it was determined that the facility failed to complete annual performance evaluation at least once every 12 months for two of two nurse aide (NA) personnel records (NA Employee E1, and E4).Findings include:Review of the facility's Employee Handbook indicated that all employees will be subject to a written annual rating and evaluations by the department supervisor based on their anniversary date. Review of NA Employee E1's personnel record indicated a hire date of 10/25/21. Review of NA Employee E1's personnel records revealed that no performance evaluation was conducted between 10/1/24 and 10/1/25. Review of NA Employee E4's personnel record indicated a hire date of 11/23/21. Review of NA Employee E4's personnel records revealed that no performance evaluation was conducted between 11/23/24, and 11/23/25. During an interview on 1/19/26, at 10:56 a.m. Human Resources Director Employee E5 confirmed that the facility failed to complete annual performance evaluation at least every 12 months for NA Employee E1, and E4. 28 Pa Code:…

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 and staff interviews, it was determined that the facility failed to provide Communication training to four of five direct care facility staff reviewed (Employees E1, E3, E4, and E6).Finding include: Review of the facility policy Continuing Education dated 9/22/25, indicated that all levels of employees are expected to complete required trainings within designated time frames. During an interview on 1/16/25, at 1:52 p.m. Human Resources Director Employee E5 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2025 revealed the following concerns: Review of Nurse Aide (NA) Employee E1's facility provided information did not include training on effective communication. Review of Registered Nurse (RN) Employee E3's facility provided information did not include training on effective communication. Review of NA Employee E4's facility provided information did not include training on effective communication. Review of RN Employee E6's facility provided…

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 and staff interviews, it was determined that the facility failed to provide Resident Rights training to four of five direct care facility staff reviewed (Employees E1, E3, E4, and E6).Finding include: Review of the facility policy Continuing Education dated 9/22/25, indicated that all levels of employees are expected to complete required trainings within designated time frames. During an interview on 1/16/25, at 1:52 p.m. Human Resources Director Employee E5 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2025 revealed the following concerns: Review of Nurse Aide (NA) Employee E1's facility provided information did not include training on Resident Rights. Review of Registered Nurse (RN) Employee E3's facility provided information did not include training on Resident Rights. Review of NA Employee E4's facility provided information did not include training on Resident Rights. Review of RN Employee E6's facility provided information did not…

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

Based on review of facility policy, facility documents and staff interviews, it was determined that the facility failed to provide Abuse and Neglect training to five of seven direct care facility staff reviewed (Employees E1, E3, E4, E6, and Director of Nursing).Finding include: Review of the facility policy Continuing Education dated 9/22/25, indicated that all levels of employees are expected to complete required trainings within designated time frames. During an interview on 1/16/25, at 1:52 p.m. Human Resources Director Employee E5 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2025 revealed the following concerns: Review of Nurse Aide (NA) Employee E1's facility provided information did not include training on Abuse and Neglect. Review of Registered Nurse (RN) Employee E3's facility provided information did not include training on Abuse and Neglect. Review of NA Employee E4's facility provided information did not include training on Abuse and Neglect. Review of RN Employee E6's 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 policy, facility documents and staff interviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to five of five direct care facility staff reviewed (Employees E1, E2, E3, E4, and E6).Finding include: Review of the facility policy Continuing Education dated 9/22/25, indicated that all levels of employees are expected to complete required trainings within designated time frames. During an interview on 1/16/25, at 1:52 p.m. Human Resources Director Employee E5 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2025 revealed the following concerns: Review of Nurse Aide (NA) Employee E1's facility provided information did not include training on QAPI. Review of Licensed Practical Nurse (LPN) Employee E2's facility provided information did not include training on QAPI. Review of Registered Nurse (RN) Employee E3's facility provided information did not include training on QAPI. Review of NA Employee E4's…

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 and staff interviews, it was determined that the facility failed to provide Infection Control training to four of five direct care facility staff reviewed (Employees E1, E3, E4, and E6).Finding include: Review of the facility policy Continuing Education dated 9/22/25, indicated that all levels of employees are expected to complete required trainings within designated time frames. During an interview on 1/16/25, at 1:52 p.m. Human Resources Director Employee E5 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2025 revealed the following concerns: Review of Nurse Aide (NA) Employee E1's facility provided information did not include training on Infection Control. Review of Registered Nurse (RN) Employee E3's facility provided information did not include training on Infection Control. Review of NA Employee E4's facility provided information did not include training on Infection Control. Review of RN Employee E6's facility provided 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.

Based on review of facility policy, facility documents and staff interviews, it was determined that the facility failed to provide Compliance and Ethics training to four of five direct care facility staff reviewed (Employees E1, E3, E4, and E6).Finding include: Review of the facility policy Continuing Education dated 9/22/25, indicated that all levels of employees are expected to complete required trainings within designated time frames. During an interview on 1/16/25, at 1:52 p.m. Human Resources Director Employee E5 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2025 revealed the following concerns: Review of Nurse Aide (NA) Employee E1's facility provided information did not include training on Compliance and Ethics. Review of Registered Nurse (RN) Employee E3's facility provided information did not include training on Compliance and Ethics. Review of NA Employee E4's facility provided information did not include training on Compliance and Ethics. Review of RN Employee E6's 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 policy, personnel records, and staff interview it was determined that the facility failed to ensure that two of two sampled Nurse Aides (NA) received a minimum of 12 hours of in-service education per year (NA Employee E1, and E4).Findings include: Review of the facility policy Continuing Education dated 9/22/25, indicated that all levels of employees are expected to complete required trainings within designated time frames. During an interview on 1/16/25, at 1:52 p.m. Human Resources Director Employee E5 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2025 revealed the following concerns: Review of personnel records revealed that NA Employee E1 did not receive 12 hours of in-service training in the last year. Review of personnel records revealed that NA Employee E4 did not receive 12 hours of in-service training in the last year. The facility was unable to provide documented evidence that NA Employees E1, and E4 had received a minimum of 12 hours of in-service…

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 and staff interviews, it was determined that the facility failed to provide Behavioral Health training to four of five direct care facility staff reviewed (Employees E1, E3, E4, and E6).Finding include: Review of the facility policy Continuing Education dated 9/22/25, indicated that all levels of employees are expected to complete required trainings within designated time frames. During an interview on 1/16/25, at 1:52 p.m. Human Resources Director Employee E5 stated that education is conducted by calendar year running January through December. Review of facility education documents for the year 2025 revealed the following concerns: Review of Nurse Aide (NA) Employee E1's facility provided information did not include training on Behavioral Health. Review of Registered Nurse (RN) Employee E3's facility provided information did not include training on Behavioral Health. Review of NA Employee E4's facility provided information did not include training on Behavioral Health. Review of RN Employee E6's facility provided 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 a review of facility job descriptions, facility documents, personnel files, and staff interviews, it was determined the facility failed to ensure that staff renewed their nurse aide registration to allow individuals to work as a nurse aide for two of 28 nurse aides (NA) reviewed (NA Employee E15, and E16).Finding include: Review of the facility document Employee Handbook indicated that persons hired as part of the professional staff are required to have and maintain a valid current license or certification. Review of facility audits on [DATE], at 3:01 p.m. revealed that 64 out of 66 licensed Facility Employees had an active, valid license. During an interview on [DATE], at 3:05 p.m. NHA 3 stated that two employees were sent home due to an inactive license. These employees were identified as NA Employee E15 whose license had expired on [DATE], and NA Employee E16 whose license had expired on [DATE]. NA Employee E15's last day working at the facility was [DATE], and NA Employee E16's last day working 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 review of job descriptions, clinical records, observations, and staff interviews, it was determined that the Nursing Home Administrator 1(NHA) and the Director of Nursing 1 (DON) failed to timely and effectively manage 12 allegations of resident neglect and failed to maintain sufficient nursing staff to provide resident care and treatment, which created an Immediate Jeopardy situation for 12 of 12 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12), and failed to ensure annual abuse and neglect prevention training was completed for five of seven staff members (Nurse Aide (NA) Employee E1, Registered Nurse (RN) Employee E3, NA Employee E4, RN Employee E6, and the Director of Nursing (DON) identified in an incident of reported neglect, and failed to provide documentation of annual abuse and neglect training for 90 of 90 current Facility Employees for 12 of 12 months (January through December 2025), and failed to screen potential employees for a history of abuse by completing pre-employment criminal background checks for one of seven employees (Licensed…

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 ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for two of two residents (Resident R16 and R17).Findings include: Review of facility policy Coordination of Hospice services dated 9/29/25, indicated: When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being. The facility maintains written agreements with hospice providers that specify the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding the resident's care. The facility and hospice provider will coordinate a plan of care and will implement interventions in accordance with the resident's needs, goals, 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 policies, observations, and staff interviews, it was determined that the facility failed to maintain proper infection control practices related to the care of clean linen, which created the potential for cross-contamination for one of two nursing floors (Second floor). Findings include:Review of facility policy Handling Clean Linen dated 9/22/25, indicated that the facility will handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection.During a tour of the second floor on 1/14/26, at 11:30 a.m. an empty clean linen cart was observed sitting by the exit stairwell door.During an interview on 1/14/26, at 11:35 a.m. Nurse Aide Employee E1 stated staff are using the empty clean linen cart to transport meal trays to residents' room and proceeded to show the state agency where linen was being kept.During an observation on 1/14/26, at 11:38 a.m. bedside tables were stored in a corridor with clean linen on them and the linen was uncovered.During an observation on 1/14/26, 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 review of facility documentation, staff and resident interview it was determined that the governing body failed to implement policies regarding the management of the operation of the facility by failing to respond to vendor invoices and failing to respond to facility requests payment for outstanding bills. Findings include: During an interview on 12/18/25, at 10:02 a.m. Nursing Home Administrator and Director of Nursing confirmed three residents had been sent of the facility to the hospital due to the facility not having transportation to get them to necessary physician appointments and medical appointments. NHA and DON stated that several transportation companies have been used throughout the year and the current transportation company indicated an outstanding bill. During an interview on 12/18/25, at 12:07 p.m. Director of Nursing confirmed that the facility is unable to obtain labs on residents due to the laboratory company indicating an outstanding bill. Review of facility documentation AP Ledger 6/25 to 11/25 indicated the following monies owed to the following…

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 and staff interview it was determined that the facility failed to follow physician orders with doctor's appointments and lab work for four of five residents reviewed (Resident R1, R2, R3, and R4).Findings include: Review of the facility policy Provision of Quality Care dated 9/22/25, indicated based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans and the residents' choices. Review of facilities Resident Right policy dated 9/22/25, indicated the facility will inform the resident both orally and in writing of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Residents have the right to participate in planning and implementing care. Review of facilities Accommodation of Needs policy dated 9/22/25, 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 and staff interview it was determined that the facility failed to provide ADL's (activities of daily living) for one of five residents reviewed (Resident R5).Findings include: Review of facility policy Activities of Daily Living (ADL's) dated 9/22/25, indicated Care and services will be provided for the following activities of daily living bathing, dressing, grooming and oral care, toileting, transfer and ambulation, and eating to include meals and snacks. Resident R5 was admitted to the facility on [DATE]. Review of Resident R5 admission information indicated diagnosis of liver cell carcinoma. Review o of Resident R5 clinical record indicated hospice services-initiated referral due to needing additional care and services that could not be provided at home. Review of Resident R2 clinical record documentation survey report for November 2025 indicated resident received care during the 11pm-7am shift on 11/20/25. Next documentation is a physician note at 1:23…

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 five of six residents (Residents R2, R3, R4, R5, and R6). Findings include: Review of facility policy Nebulizer Therapy dated 9/22/25, indicated care of equipment includes clean after each use, disassemble parts after every treatment, rinse the nebulizer (a machine used to deliver aerosolized medications) cup and mouthpiece with sterile or distilled water, and once completely dry, store the nebulizer cup and the mouthpiece in a Ziplock bag. Change nebulizer tubing every seventy-two hours or per facility policy. Review of the facility policy Oxygen Concentrator dated 9/22/25, indicated change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Change humidifier bottle when empty, every seventy-two hours, or as recommended by the manufacturer. The main body cabinet should be dusted when needed 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 facility policy, clinical record review, facility documents, observation, and staff interview, it was determined that the facility failed to ensure proper hand hygiene for enhanced barrier precautions (EBP) in eight of eight resident rooms with EBP signage on the doors (Rooms 104, 108, 202, 216, 220, 221, 222, and 223).Findings include: Review of the facility policy Enhanced Barrier Precautions dated 9/22/25, indicated implementation of EBP: make gowns and gloves available immediately near or outside of the resident's room. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). During an interview and tour on 9/30/25, at 8:48 a.m. with Licensed Practical Nurse (LPN) Employee E2 indicated we've been bringing in our own soap and paper towels. Resident bathrooms in rooms 104, 105, 108, 110, 112, and 118, were confirmed to not have soap in the dispenser or any paper towels in the dispenser. During an interview on 9/30/25, at 8:53 a.m. Nurse Aide (NA) Employee E3 indicated staff do not have anything to wash their hands 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, resident and staff interviews, it was determined that the facility failed to afford residents the right to self-administer medication for one of three residents (Resident R1).Findings include:Review of facilities Resident Right policy dated 9/22/25, indicated the facility will inform the resident both orally and in writing of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Residents have the right to participate in planning and implementing care. Residents have the right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate. Review of facilities Self-Administration by Resident policy dated 9/22/25, indicated the residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would…

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 provide a clean, safe, comfortable, and homelike environment for 12 out of 15 resident rooms (Rooms 102, 107, 114, 116, 119, 204, 206, 208, 216, 224, 225, and 226), and one out of two resident common rooms (Second Floor). Findings include: Review of facility Safe and Homelike Environment policy dated 9/22/25, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable, homelike environment. This includes ensuring that the residents can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. During a tour of the facility on 11/19/25, at 10:00 a.m. with Licensed Practical Nurse (LPN) Employee E1 the following were observed: Resident room [ROOM NUMBER]'s bathroom failed to have a working and functional hand soap dispenser. Resident room [ROOM NUMBER]'s bathroom failed to have…

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 follow a physician order for one out of three residents (Resident R2) and failed to make certain that residents were provided appropriate treatment and care for one of three residents (Residents R1). Findings include: Review of the facility policy Provision of Quality Care dated 9/22/25, indicated based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans and the residents' choices. Review of facilities Resident Right policy dated 9/22/25, indicated the facility will inform the resident both orally and in writing of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Residents have the right to participate in planning and implementing care. 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, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents for two of three residents (Resident R1 and R2). Findings include: Review of the facility policy Incidents and Accidents dated 9/22/25, indicated it is the policy of the facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Review of facility policy Activities of Daily Living dated 9/22/25, indicated the facility will, based on the resident's comprehensive assessment and consistent with the residents' needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following ADLs: bathing, dressing, grooming and oral care; transfer and ambulation, toileting, eating to include meals and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to accommodate the proper linen needs for three of five residents (Residents R2, R3, and R9). Findings include: A review of facility policy Safe and Homelike Environment dated 12/9/24, indicated in accordance with residents ' rights, the facility will provide a safe, clean, comfortable and homelike environment. This includes ensuring that the resident can receive care and services safely. Environment includes any environment in the facility that is frequented by residents, including, but not limited to, the residents' room, bathrooms, hallway, dining area. A review of facility policy Accommodation of Needs dated 12/9/24, indicated the facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered. During 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 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 four of five residents reviewed (Residents R6, R7, R5, and R8) and failed to adhere to tube site dressing care for one of four residents (R8). Findings include: Review of the facility policy Care and Treatment of Feeding Tubes (delivery of food or medication via tube surgically inserted into stomach) dated 12/9/24, indicated the facility must utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Review of the facility policy Enteral Medication Administration dated 12/9/24, indicated to reconnect tube or clamp as indicated. Rinse the syringe and allow it to air dry. Store in a plastic bag. Change syringe every 24 hours. Review of the clinical record revealed that Resident R6 was admitted to 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 facility documents, observations, and staff interviews, it was determined that the facility failed to maintain a homelike environment for one of two floors (First Floor). Findings include: A review of facility policy Safe and Homelike Environment dated 12/9/24, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. This includes ensuring that the resident can receive care and services safely. Environment includes any environment in the facility that is frequented by residents, including, but not limited to, the residents' room, bathrooms, hallway, dining area. During a tour of the unit on 7/1/25, at 8:58 a.m. the following were observed: - room [ROOM NUMBER] - Hole in the wall located by the air conditioner unit - room [ROOM NUMBER] - Bathroom vent had dust build up, bathroom plaster on the ceiling was peeling - room [ROOM NUMBER] - Bathroom vent had dust build up - room [ROOM NUMBER] - Bathroom plaster on the ceiling…

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, facility documents, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain residents were free from neglect and mistreatment by giving the wrong medication to a resident after resident refusal for one of three residents (Resident R4). Findings include: The facility policy Abuse, Neglect, Mistreatment Education dated 12/9/24, indicated the facility prohibits mistreatment, neglect, and abuse of residents by anyone including staff, family friends, etc. Neglect - Failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect of goods or services may occur when staff are aware, or should be aware, of residents' care needs, but are unable to get the identified needs due to other circumstances, such as lack of training to perform an intervention, lack of supplies, or lack of staff knowledge of the needs of the resident. Review of the facility policy 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, resident records and staff interview, it was determined the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of three residents (Resident R5). Finding include: Review of the facility policy Transfer and Discharge (including AMA) dated 12/9/24, indicated for a transfer to another provider, for any reason, the following information must be provided to the receiving provider: specific information to the receiving health care provider which includes the resident's care plan goals, advanced directive information, specific instructions for ongoing care, and all information necessary to meet the resident's specific needs at the receiving facility. Review of the admission record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/3/25, indicated the diagnosis of stroke (damage to the brain from 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 review of facility policy, observation, clinical record, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of three residents (Resident R4). Findings include: Review of the facility policy Medication Administration dated 12/9/24, indicated medications are administered by licensed nurses, as ordered by the physician and in accordance with professional standards or practice. Identify resident by photo in the Medication Administration Record (MAR). Review MAR to identify medication to be administered. Compare medication source (pack, vial, etc.) with MAR to verify resident's name medication name, form, dose, route, and time. Administer medication as ordered. Sign MAR after administration. Review of the facility policy Medication Administration dated 5/1/24, indicated medications ordered for one resident are never administered to another resident. Review of admission record indicated Resident R4 admitted to 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 facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to prevent cross contamination with residents' personal toiletries for two of five bathrooms on the First Floor (Rooms 107, and 118). Findings include: A review of facility policy Safe and Homelike Environment dated 12/9/24, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. This includes ensuring that the resident can receive care and services safely. Environment includes any environment in the facility that is frequented by residents, including, but not limited to, the residents' room, bathrooms, hallway, dining area. A review of facility policy Infection Prevention and Control Programs dated 12/9/24, indicated the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development 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 facility policy review, observations, resident council group interview, resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of two shower rooms (One-West), one clean utility room (One-East) and four out of five resident rooms (Resident R22, R46, R61, and Resident R63) and the facility failed to maintain an adequate supply the following day of wash clothes, towels, and blankets readily available for two of two nursing units. Findings include: The facility Safe and homelike environment policy reviewed 12/9/24, indicated that the facility will provide a safe, clean, comfortable and homelike environment. During a tour on 4/15/25, at 9:30 a.m. the following was observed in the clean utility room on One-East with the Director of Maintenance/ Housekeeping Employee E13: - the ice machine water outlet was observed with brown substance on water outlet. PC-piping behind the ice machine was found with black spotted substance on PC-piping leading to the drain. During an interview on 4/15/25, at 9:31 a.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and resident and staff interviews, it was it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for three of four residents (Resident R16, R23, R52 and R128). Findings include: Review of the clinical record revealed that Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/7/25, indicated diagnoses of right below the knee amputation, diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) , and peripheral vascular disease (a slow and progressive disease that impacts the blood vessels in the body outside the heart.) Review of Resident R16's active physician order dated 3/17/25, indicated to cleanse Resident R16's diabetic left plantar foot ulcer with normal saline solution (wound cleanser), pat dry, apply Mupirocin ointment…

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, 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 five sampled nursing personnel records (Registered Nurse (RN) Employee E16 , Licensed Practical Nurse (LPN) Employee E25, and Registered Nurse (RN) Employee E26). Findings include: The facility Training requirements policy last reviewed on 12/9/24, indicated that the facility will develop, implement and maintain an effective training program for all new and existing staff. Training contents includes, at the minimum communication, resident rights, elements of the facility's QAPI (quality assurance and performance improvement), infection control, ethics, behavioral health, dementia management, abuse/ neglect, and safety and emergency procedures. Review of Registered Nurse (RN) Employee E16 personnel record indicated she was hired on 11/3/10. Review of Licensed Practical Nurse (LPN) Employee E25 personnel record indicated she was hired 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, clinical records, and staff interviews it was determined that the facility failed to implement pharmaceutical services to ensure accurate provision of medications for one of four residents (Residents R51 and Resident R128). Findings include: Review of the facility policy, Pharmacy Services last reviewed 12/9/24, indicated to ensure pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. The facility will maintain a limited supply of medications for emergency or after-hours situations in accordance with facility policy and applicable laws. Review of the facility policy Unavailable Medications last reviewed 12/9/24, indicates the facility maintains a contract with a pharmacy provider to supply the facility with routine, prn, and emergency medications. The facility shall follow established procedures for ensuring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that any irregularities submitted in the medication regimen reviews (MRR) by pharmacy were acted upon timely for two out of two residents (Resident R2 and R69). Findings include: Review of facility policy Medication Regimen Review last reviewed on 12/9/24, indicated the drug regimen is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. The MMR, or drug regimen review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risk associated with medication. The MMR includes: a. Review of the medical record in order to prevent, identify, report, and resolve medication related problems, medication errors, or other irregularities. b. Collaboration with other members of the interdisciplinary team, including the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, and staff interview it was determined the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days, and failed to monitor the effectiveness or adverse consequences of psychotropic medication use for one of three residents (Resident R2) reviewed. Findings Include: Review of facility policy Use of Psychotropic Medications dated 12/9/24, indicated this policy is to ensure that residents only receive psychotropic mediations when other nonpharmacological interventions are clinically contraindicated. Additionally, these medication should only be used to treat the resident's medical symptoms and not used for disciple or staff convenience. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. Psychotropic medications are to be used only when a practioner…

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, facility scheduled mealtimes, resident council group interview, and staff interviews it was determined that the facility failed to ensure the provision of a nourishing (satisfying to the resident) evening snack when greater than 14 hours elapsed from the supper meal to breakfast the next day for residents including three of three residents sampled (Residents R73, R377, and R378), and failed to [NAME] resident group acceptance of a meal span of greater than 14 hours. Findings include: A review of facility policy Offering/Serving Bedtime Snacks, dated 12/9/24, indicates that it is the practice of the facility to offer and serve residents with a nourishing snack in accordance with their needs, preferences and requests at bedtime on a daily basis. The nursing staff offers bedtime snacks to all residents in accordance with the resident's needs, preference and requests on a daily basis. Intake of bedtime snack is documented in the medical record. A review of facility's Meal Times…

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 documents, and resident and staff interview, it was determined that the facility failed to provide specialized rehabilitative services for three of three residents (Resident R16 and R237). Findings Include: Review of the facility policy Therapy Evaluation dated 12/9/24, stated the licensed therapist will perform an initial resident evaluation upon physician referral and any reevaluation where indicated. The Rehabilitation Department will be notified when a physician order is written for therapy evaluation and treatment. Review of the facility policy Therapy Treatment Procedures for Therapeutic Exercise dated 12/9/25, stated it is the facility's policy to provide therapy treatment procedures for therapeutic exercise as necessary. Review of the clinical record revealed that Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's care plan dated 1/2/25, indicated for therapy to evaluate and treat as ordered and as needed. Review of Resident R16'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 review of clinical records and staff interview it was determined that the facility failed to employ a full time social worker. Findings include: Review of clinical records for Resident R16, and Resident R128, Resident R278 clinical records indicated the NHA was completing social service documentation. During an interview on 4/17/25, at 3:28 p.m. confirmed that the facility did not have a fulltime social worker, and that the NHA has been filling in for the social worker. The facility has been without a social for approximately a month and that the facility failed to employ a full tie social worker to meet residents psychosocial needs. Refer to F699, F740, and F745. 28 Pa.Code: 211.16. (a) Social services.

Based on review of facility policy, Quality Assurance attendance records, 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 three of four quarters (April 2024 through June 2024 and July 2024 through December 2024). Findings include: Review of facility policy Quality Assessment and Assurance Committee last reviewed 12/9/24, indicated the facility will maintain a QAA Committee to identify quality issues and develop appropriate plans of action to correct quality deficiencies through an interdisciplinary approach. The committee will be composed of the following staff at a minimum. -Director of Nursing -Medical Director or his/her designees -The Infection Preventionist -At least three other facility staff members, one of which will be the Administrator, owner, a board member, or other individual in a leadership role. The facility failed to have the QAPI Committee meeting sign-in sheets from the period of April 2024 through June 2024 available for…

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

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to follow enhanced barrier precautions for two of five residents (Resident R13 and R68), failed to prevent cross contamination during a dressing change for one of three residents (Resident R68), and failed to implement an infection control program that included a system of surveillance that included tracking, trending and mapping to identify possible communicable diseases or infections for one of six months (January 2025). Findings include: Review of the facility policy Dressings, Dry/Clean, last reviewed 12/9/24, indicates the purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Steps in the procedure include but are not inclusive to: -Clean bedside stand. Establish a clean field. -Place the equipment on the clean field -Tape a biohazard or plastic bag on the bedside stand or use a waste basket below clean field -Wash and dry hands -Put on clean gloves -Cleanse wound -Discard items -Remove gloves, wash and dry hands -Apply 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 a review of select facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections (Mid-October 2024, to 2/21/25). Findings included: The Centers for Medicare and Medicaid Services regulation §483.80(b)(3) states the facility must designate one or more individuals as the infection preventionist who are responsible for the facility's Infection Prevention and Control Program. The IP (infection preventionist) must work at least part-time at the facility, physically work onsite in the facility, have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field, cannot be an off-site consultant or perform the IP work at a separate location. During an interview on 4/17/25, at 1:56 p.m., the IP, Employee E18 stated, I can't tell you an exact start date, I would say sometime in January they combined the wound care position with infection control, the other nurse handed it to 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, closed clinical records, resident fund account statements and staff interview it was determined that the facility failed to convey resident funds in accordance with State law and closed accounts upon discharge in a timely manner for one out of two sampled records (Closed Resident Record CR984). Findings include: The facility Resident personal funds policy last reviewed 12/9/24, indicated that upon discharge, eviction or death of a resident with a personal fund deposited with the facility, the facility will convey within 30 days the resident's funds and a final account of those funds. Review of Closed Resident Record CR984's admission record indicated he was admitted on [DATE]. Review of Closed Resident Record CR984's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 10/8/24, indicated he had diagnoses that included chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of facility provided documents, clinical records, and staff interview, it was determined that the facility failed to thoroughly investigate to rule out potential neglect for two of four residents (Resident R23 and R24). Findings include: Review of facility policy Abuse, Neglect, Mistreatment Education last reviewed 12/9/24, indicated that the facility prohibits the mistreatment and neglect of residents. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident neglect and mistreatment. Neglect is the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The Administrator and Director of Nursing are responsible for investigating and reporting incidents of neglect. Upon receiving an incident or suspected incident of abuse or neglect, the Administrator/DON/designees will conduct an investigation to include interviews of any…

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, admissions documentation, billing documents, resident and staff interviews it was determined that the facility failed to maintain admission documentation for two of four sampled residents (Resident R32 and Resident R57) and failed to provide a comprehensive review of resident admission rights, policies, and payment requirements for two of four residents (Resident R62 and R66). Findings include: The facility Resident rights policy reviewed 12/9/24, indicated that the facility will inform the resident both orally and in writing of his or her rights and regulations governing resident conduct and responsibilities during the stay in the facility. Review of Resident R32's admission record indicated she was admitted on [DATE]. Review of Resident R32's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 4/6/25, indicated she had diagnoses that included diabetes (metabolic disorder impacting organ function related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, resident records and staff interview, the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two out of three residents sampled with facility-initiated transfers (Resident R47 and R76). Finding include: Review of Resident R47's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of intellectual disabilities, dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident R47's progress note dated 3/17/25, indicated the resident was heard making grunting noises from his room at 3:25 a.m. The resident was sitting upright at his bedside pointing to his chest and throat, unable to speak. The resident's…

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, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two of two residents (Resident R47, and R76). Findings Include: Review of Resident R47's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of intellectual disabilities, dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident R47's clinical record revealed that the resident was transferred to the hospital on 3/17/25, and returned to the facility on 3/20/25. A review of Resident R47's clinical record indicated the facility failed to include documented evidence that the facility provided a copy…

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, and staff interviews, it was determined that the facility failed to provide evidence that a written notification of the facility bed hold policy was provided to the resident upon transfer to the hospital for two of two residents (Resident R47 and R76). Findings Include: Review of Resident R47's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of intellectual disabilities, dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident R47's clinical record revealed that the resident was transferred to the hospital on 3/17/25, and returned to the facility on 3/20/25. A review of Resident R47's clinical record failed to include documented evidence that the resident 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.

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 provide language assistance services to maintain activities of daily living (ADLs) for communication for one of two residents (Resident R177). Findings include: The facility Language assistance services policy reviewed 12/9/24, indicated that the facility will take responsible steps to ensure that individuals with limited English proficiency have access to language assistance services and meaningful communication involving their medical treatment. Review of Resident R177's admission record indicated she was admitted on [DATE]. Review of Resident R177's initial nurse assessment dated [DATE], indicated she had diagnoses that included hypotension (low blood pressure), wound of the left heel and cellulitis (bacterial infection of the skin causing redness, aches, and swelling) of both lower extremities. The assessment identified Resident R177 primary language as French. Review…

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, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for two of three residents (Residents R13 and Resident R35). Findings include: Review of facility policy Care and Treatment of Feeding Tubes dated 12/9/24, indicated the facility will utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Feeding tubes will be utilized according to physician orders. The resident's care plan will address the use of feeding tube, including strategies to prevent complications. In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location; tube placement will be verified before beginning a feeding and before…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, observations, and resident and staff interviews, it was determined that the facility failed to provide effective pain management for one of four residents reviewed (Resident R16). Findings include: Review of the clinical record revealed that Resident R16 was admitted to the facility on [DATE], with diagnoses of right below the knee amputation, diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces), and peripheral vascular disease (a slow and progressive disease that impacts the blood vessels in the body outside the heart.) Review of Resident R16's care plan dated 1/3/25, revealed the resident was care planned for pain. Interventions included to administer medication per physician orders. Review of Resident R16's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/7/25, indicated diagnoses were current. Review of Resident R16's…

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 and staff interviews, it was determined that the facility failed to maintain a complete record of a dialysis contract for one of two sampled residents (Resident R22). Findings include: Review of Resident R22's admission record indicated she was admitted [DATE]. Review of Resident R22's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 2/12/25, indicated she had diagnoses that included end stage renal disease (gradual loss of kidney function), chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and vascular dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning). Review of Resident R22's care plan dated 2/12/25, indicated she had dialysis three times a week Review of Resident R22's physician orders dated 2/28/25, indicated that she was…

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 R278). Findings include: Review of facility policy Comprehensive Care Plans last reviewed 12/9/24, revealed it is the policy of the facility to develop and implement a comprehensive care plan for each resident, consistent with resident rights, that includes measureable objectives and timeframes to meet a resident's medica;, nursing, mental, and psychosocial needs and all services that are identified in the resident's comprehensive assessment and [NAME] professional standards of quality. Review of the clinical record indicated Resident R278 was admitted to the facility on [DATE]. Review of Resident R278's physician order dated 4/1/25, indicated to consult psychiatry. Review of Resident R278'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 clinical record review, facility policy and interviews with staff, it was determined that the facility failed to ensure a medication was signed off by a physician prior to administering, and timely provide care and necessary treatment and services for one of two residents (Resident R52). Findings include: Review of the facility policy Administering Medications last reviewed 12/9/24, revealed medications are administered vin a safe and timely manner, and as prescribe. If dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associate with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. Review of the facility policy Provision of Quality Care last reviewed 12/9/24, revealed the facility will ensure residents receive treatment…

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 and resident interview, it was determined that the facility failed to provide behavioral health interventions for a resident to maintain the highest practicable mental well-being for one of four residents reviewed for behavioral concerns (Resident 16). Findings include: Review of the clinical record revealed that Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's active physician order dated 1/2/25, indicated to consult psychiatry. Review of Resident R16's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/7/25, indicated diagnoses of right below the knee amputation, diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) , and peripheral vascular disease (a slow and progressive disease that impacts the blood vessels in the body outside the heart.) Review of Resident R16's care plan dated 1/14/25, revealed 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 provide medically related social services to one of two residents reviewed (Resident R128). Findings include: Review of the clinical record indicated that Resident R128 was admitted on [DATE]. Review of Resident R128 MDS indicated a diagnosis of depression (a common and serious mental disorder that negatively affects how you feel, think, act, and perceive the world), hypokalemia ( potassium blood level low), and seizure disorder (a brain condition that causes recurring seizures). Review of Resident R128 physician orders dated 1/18/25, indicated to administer Selegeline Transdermal Patch 24 Hour 12 MG/24 HR, one patch transdermally (on top of skin) at bedtime for depression related to major depressive disorder Review of Resident R128 MAR (medication administration record) and review of clinical progress notes indicated missed doses of selegeline for multiple days: 1/18/25 thru 1/26/25. Review of Resident R128…

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 properly store medical supplies and biologicals in one of two medication rooms (second floor medication room) and two of four medication carts (first floor west and second floor west medication cart) failed to date open medications in two of four medication carts (first floor west and second floor west medication cart) and treatment medications were found unsecured at a resident's bedside for one of four residents (Resident R69). Findings include: Review of the facility policy Medication Storage last reviewed 12/9/24, indicate it is the policy of this facility to ensure all medications housed on premises will be stored in the pharmacy and/or medication rooms according to the manufactures recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. External products disinfectants and drugs used for external use are…

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 interview, it was determined that the facility failed to provide accurate and timely documentation related to the Influenza and Pneumonia vaccine for two of five residents (Resident R13 and R60). Findings include: Review of facility policy Influenza, Prevention and Control of Seasonal last reviewed 12/9/24, indicates this facility follows current guidelines and recommendations for the prevention and control of seasonal influenza. All residents and staff are offered the vaccine prior to the onset of the influenza season. Review of the facility policy Pneumococcal Vaccine last reviewed 12/9/24, indicates all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated…

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 equipment was in safe operating condition in the main kitchen and the facility failed to maintain essential equipment with a dryer not working ( 1 of 2 dryers). Findings include: Review of Code of Federal Regulations §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. During an observation on 4/17/25, at 12:35 p.m., it was revealed that the main kitchens six well steam table (a type of commercial food service equipment that is used to keep foods at optimal serving temperatures) was operating with only three steam wells. During an interview on 4/17/25, at 1:32 p.m., Dietary Manager (DM) Employee E11 confirmed that only three of six steam table wells are functioning time of interview. Further interview revealed that DM Employee E11 was hired in December 2024, and at that time, 2 steam wells were broke and not functioning. DM Employee E11 stated that the third steam well just broke within the last few weeks. During 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.

Based on review of facility policy, employee personnel records, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation on the date of orientation for one out of five sampled records (Physical Therapist Employee E3). Findings include: The facility Abuse, neglect, and misappropriation education policy reviewed 12/9/24, indicated to abuse, neglect, and misappropriation of resident funds education is completed upon hire and at least annually for all employees. Review of Physical Therapist Employee E3 personnel record indicated she was hired on 3/31/25. Facility punch detail report (Report indicating which days staff worked) dated 4/17/25, indicated that Physical Therapist Employee E3 worked at the facility for five days in April of 2025. Review of Physical Therapist Employee E3 personnel record did not include abuse training during her orientation to the facility. During an interview on 4/17/25, at 12:34 p.m. the Human Resources Employee E5 confirmed that the facility failed to provide training on Abuse, Neglect, 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 observations and staff interview, it was determined that the facility failed to properly label and date food products in the walk in freezer and dry storage in the designated main kitchen and failed to maintain sanitary conditions which created the potential for cross contamination (Main Kitchen). Findings include: During an observation of the main designated kitchen on 3/18/25, at 9:05 a.m. the following was observed: -2 bags of frozen biscuits-no label -1 bag of chicken nuggets-no label -1 bag of french fries- no label -4 bags of cheerios-no label -3 bags of rice krispies- no label -3 bags of fruit loops- no label -4 bags of corn flakes- no label During an trayline observation of the main designated kitchen on 3/18/25, at 11:45 a.m. the following was observed: -Cook Employee E4 holding clean plates against his shirt two times -Cook Employee E5 touched the convection oven and stove, then touched hamburger buns without changing his gloves During an interview on 3/18/25 at 12:15 p.m. Dietary Manger Employee E2 confirmed that the facility failed to properly label and 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 record review, and staff interview, it was determined that the facility failed to provide discharge planning that focuses on the resident's discharge goals and preparation of resident to be active partners in the discharge planning process that focuses on the resident's discharge planning and process for one of three residents (Resident R4). Findings include: 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 11/13/24, indicated diagnoses of hyperlipidemia (high levels of fat in the blood), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and chronic pain syndrome. Review of a physician order dated 12/27/24, indicated to discharge resident home with meds and home care. Resident verbalizes understanding. Review of a Social Services progress note dated 12/27/24, stated, Resident discharged 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 record review, and staff interview, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for two of four residents (Residents R2 and R3). Findings include: Review of facility policy Activities of Daily Living dated 12/9/24, indicated the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: - Bathing, dressing, grooming, and oral care; - Transfer and ambulation; - Toileting; - Eating to include meals and snacks; and - Using speech, language or other functional communication systems A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the clinical record 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 facility policy, clinical record, and staff interview, it was determined that the facility failed to provide medications as ordered by the physician for one of five residents (Resident R5). Findings include: Review of facility policy Medication Administration dated 12/9/24, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Sign MAR (medication administration record) after administered. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/5/25, indicated diagnoses of high blood pressure, anxiety, and depression. Review of a physician order dated 3/31/24, indicated to administer Lipitor (used to treat high cholesterol) 40 mg (milligrams) by mouth every…

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, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Residents R1 and R2). Findings include: Review of facility policy Oxygen Concentrator dated 12/9/24, indicated to change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. 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 2/27/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and obstructive sleep apnea. Review of a physician order dated 6/4/24, indicated to change oxygen tubing weekly and label each component with date and initials every night shift every Sunday. Review of a physician order dated 6/14/24, indicated to administer oxygen at 2 liters/minute via nasal cannula (a lightweight tube that delivers oxygen into…

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 interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R5). Findings include: Review of facility policy Medication Administration dated 12/9/24, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Sign MAR (medication administration record) after administered. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/5/25, indicated diagnoses of hypertension (high blood pressure), anxiety, and depression. Review of a physician order dated 1/11/25, indicated to administer Carvedilol 12.5 mg…

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 menu, observation, and staff interview, it was determined that the facility failed to follow the portion sizes for one of one meal observed. Findings include: A review of the menu indicated that the menu for lunch was as follows: 3 oz Beef Tips/gravy 4 oz Rice 4 oz Caramelized Carrots 4 oz Gelatin During an observation of tray line in the main kitchen on 3/18/25, at 11:45 a.m., it was revealed that the following was being served: 4 oz ladle Beef Tips/gravy 2 oz Minced Beef 4 oz Rice Unlabeled pasta scoop for carrots 2 oz Minced Carrots During an interview on 3/18/25, at 12:15 p.m. Dietary Manager Employee E1 confirmed that tray line was using the wrong portion scoops to serve the meal. 28 Pa. Code: 211.6(a)(b) Dietary services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff interview, it was determined that the facility failed to maintain a clean, safe, and homelike environment for three of three resident rooms (rooms [ROOM NUMBER]), and failed to have an ample supply of linen at the staff's immediate disposal on four of five hallways (2East, 2West, 1 East, and 1West). Findings Include: Review of the facility policy Safe and Homelike Environment dated 12/9/24, indicated in accordance with resident's rights, the facility will provide a safe, clean, comfortable, and homelike environment. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. The facility will provide and maintain bed and bath linens that are clean and in good condition. During observations of the Second-floor nursing unit on 12/27/24, at 9:28 a.m. the following was observed: -the Second-floor nursing unit found 12 allocated beds not prepared for resident use as follows: -room [ROOM NUMBER] indicated four 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 policy, resident records, admission documentation and staff interview it was determined that the facility failed to disclose and provide to a resident or potential resident prior to time of admission, notice of special characteristics or service limitations of the facility for one of three residents (Closed Resident Record CR1). Findings include: Review of the facility policy Admission dated 12/9/24, indicated a nursing facility must disclose and provide to a resident or potential resident, prior to time of admission, notice of special characteristics or service limitations of the facility. Review of the hospital referral for Resident CR1 indicated resident with suspect mild to moderate Alzheimer's dementia (a progressive disease that destroys memory and other important mental functions), delirium (serious disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings) precautions. Further review of the hospital referral for Resident CR1 dated 12/13/24, at 1:41 p.m. indicated a consult for rapidly progressive…

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

Based on facility policy, clinical record review and staff interviews, it was determined the facility failed to notify the physician of a medication error for one of three residents. (Resident R1) Findings include: A review of the facility policy Medication Administration dated 5/1/24, indicated medications are administered, as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so to comply with Federal Laws governing Medication Administration and in order to ensure the safe, accurate and timely administration of medications. 14. If a dose of regularly scheduled medication is refused or not available the physician and responsible party will need to be notified. A reason is documented in the progress note provided in the E-MAR (electronic Medication Administration Record). A review of the clinical record indicated that Resident R1 was admitted to the facility 3/14/24, with diagnoses interstitial pulmonary disease (a group of disorders that cause scarring and damage to lung tissue, making it harder to breathe and get…

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

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician for one of four residents (Resident R1). Findings include: A review of the facility policy Medication Administration dated 5/1/24, indicated medications are administered, as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so to comply with Federal Laws governing Medication Administration and in order to ensure the safe, accurate and timely administration of medications. A review of the clinical record indicated that Resident R1 was admitted to the facility 3/14/24, with diagnoses interstitial pulmonary disease (a group of disorders that cause scarring and damage to lung tissue, making it harder to breathe and get oxygen), morbid obesity, and high blood pressure. A review of Resident R1's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 8/22/24, indicated the diagnoses remain current upon review. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for two of three residents (Residents R1, and R2) Findings include: A Review of the facility policy Medication Reordering last reviewed 7/29/24, indicated it is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medication and biologicals in a timely manner to meet the needs of each resident. A review of facility provided PharMerica Spring Hill General Information Sheet Spring Hill Medication Ordering indicates order refills according to the refill after date on the label. Refill orders received before 3:30 p.m. will be processed the same day. Refill orders received after 3:30 p.m. will be delivered the next pharmacy business day. Control orders can only be delivered upon receipt of a valid script from the prescriber. A review of Resident R1's…

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 a safe and comfortable environment in one resident room on the 1st floor. Findings include: Observations during tour of the first floor on 5/15/24, at 10:30 a.m. revealed the following Resident R1 Room: -three oxygen canister's, 1 secured, 2 unsecured -Resident R2 Broda chair blocking Resident R1 closet door During an interview on 5/15/24, at 1:45 p.m. the Nursing Home Administrator confirmed the facility failed to provide a safe and comfortable environment in one of one resident rooms. 28 Pa. Code 201.18(b)(3) Management

Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to maintain kitchen equipment and dry storage area in a clean, sanitary condition, failed to properly monitor food temperatures, and failed to verify the sanitizing temperature of the dish machine in the Main Kitchen (Main Kitchen), which created the potential for cross-contamination and/or food borne illness. Findings Include: Review of facility policy Food Safety Requirements, dated 1/18/24, stated that it is the policy of the facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. Review of facility policy Food Temperatures, dated 1/18/24, 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, observations, resident council group interview, and resident and staff interviews, it was determined that the facility failed to have an ample linen supply at the staff 's immediate disposal on 3 of 5 halls (2 East, 2 North, and 2 West). Findings include: Review of the facility Accommodation of Needs policy dated 1/18/24, indicated the facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident to maintain and/or achieve independent functioning, dignity, and wellbeing to the extent possible. Observation of the Second Floor, main linen cart outside of room [ROOM NUMBER] on 4/22/24, at 11:15 a.m. indicated there were barren linen supplies, especially sheets (three fitted sheets and seven flat sheets), towels (eight towels), gowns (three gowns) and wash cloths (seven wash cloths). Interview on 4/22/24, at 11:30 a.m. Nurse Aide (NA) Employee E6 confirmed the linen supplies…

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 minutes, group and staff interviews, it was determined that the facility failed to provide written response to resident concerns and grievances identified during resident council minutes for six of six months (October 2023, November 2023, December 2023, January 2024, February 2024, and March 2024). Findings include: Review of the facility policy dated 1/18/24, Resident and Family Grievances/Concerns indicated the Grievance Official, or designee will keep the resident appropriately apprised of progress towards resolution of the grievance and issue written grievance decisions to the resident. Review of Resident Council meeting minutes for the meetings on 10/31/23, 11/30/23, 12/28/23, 1/30/24, 2/27/24, and 3/27/24, failed to include communication to the Resident Group any resolution to their concerns included in the meeting minutes. Interview with the Resident Council President, Resident R1 on 4/23/24, at 11:00 a.m. indicated They do not tell us what the resolution is. Interview with the Nursing Home Administrator on 4/23/24, at 1:35…

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, and staff interview, it was determined that the facility failed to maintain a clean and homelike environment in two of three nursing hallways on the second floor (2 East and 2 North Hallways). Findings Include: Review of the facility policy Safe and Homelike Environment dated 1/18/24, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment, and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Observations on 4/22/24, at 9:12 a.m. indicated the lounge across from room [ROOM NUMBER] with sticky tables, linen bruits and carts, a Hoyer lift, and a Geri-chair (a type of reclining wheelchair). The perimeter of the hallway was covered in grime and had splatter paint marks scattered throughout. Interview on 4/22/24, at 9:15 a.m. Nurse Aide (NA) E5 confirmed the items in the lounge and appearance of hallway floor. Observation on 4/22/24, at 9:18 a.m. indicated room [ROOM…

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 ensure that residents received an updated elopement assessment after a discontinued wanderguard, and a neurological assessment after an incident involving a fall for three of six residents (Resident R3, R62 and R271) Findings include: Review of facility policy Fall Prevention Program dated 1/18/24, indicated when any resident experiences a fall, the facility will assess the resident, complete a post-fall assessment, complete an incident report, notify physician and family review the resident's care plan and update as indicated, document all assessments and actions, and obtain witness statements in the case of injury. Review of facility policy Incidents and Accidents dated 1/18/24, indicated in the event of an unwitnessed fall or a blow to the head, the nurse will initiate neurological checks as per protocol and document on the neurological flow sheet. Abnormal findings…

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 three of five residents (Resident R37, R61, and R272). Findings include: Review of facility policy Oxygen Concentrator dated 1/18/24, indicated the nurse shall verify physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula, etc.). Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Change humidifier bottle when empty, every seventy-two hours, or as recommended by the manufacturer. Review of admission record indicated Resident R37 was admitted to the facility on [DATE]. Review of Resident R37's Minimum Data Set (MDS- a periodic assessment of care needs) dated 3/11/24, indicated the diagnoses of chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), heart failure (heart doesn't pump blood…

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

Based on review of the clinical record and staff interview, it was determined that the facility failed to provide documentation that it acted on the pharmacy recommendations for two of five residents (Resident R21 and R62). Findings include: Review of Resident R21 and Resident R62's clinical records indicated Pharmacist Medication Regimen Reviews were completed at least monthly. Review of Resident R21's reviews completed on the following dates: -1/16/24 indicated Pharmacy Drug Regimen Review -Irregularities noted: Medical Chart Reviewed. Recommendation Made. -2/13/24 indicated Pharmacy Drug Regimen Review - Irregularities noted: Medical Chart Reviewed. Recommendation Made. -3/20/24 indicated Pharmacy Drug Regimen Review - Irregularities noted: Medical Chart Reviewed. Recommendations Made. -4/17/24 indicated Pharmacy Drug Regimen Review - Irregularities noted: Medical Chart Reviewed. No Recommendation Made. Review of Resident R62's reviews completed on the following dates: -1/17/24 indicated Pharmacy Drug Regimen Review - Irregularities noted: Medical Chart Reviewed. No…

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 implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for seven of ten months (July 2023, August 2023, September 2023, October 2023, November 2023, December 2023, and March 2024) and failed to implement enhance barrier precautions for five of six residents (Resident R6, R21, R59, R271, and R272). Findings include: Review of facility policy Infection Control Plan, Program and Committee dated 1/18/24, indicated the facility will maintain ongoing monitoring for occurrence of infections among residents and staff. Review of facility policy Isolation - Categories of Transmission-Based Precautions dated 1/18/24, indicated enhanced barrier precautions (EBP) are in place for residents with an infection or colonization of a multi-drug resistant organism (MDRO) wounds and/or indwelling medical devices, such as 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.

Based on review of facility policy, observation and staff interview, it was determined that the facility failed to determine it was safe to self-administer medications for one of six residents (Resident R36). Findings include: Review of the facility policy, Medication Administration dated 1/18/24, indicated are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. During an observation on 4/22/24, at 9:30 a.m. Resident R36 had Albuterol Sulfate Inhaler on his bedside table. Review of Resident R36's plan of care updated 3/14/24, failed to include a care plan for self-administration of medications. During an interview on 4/22/24, at 10:30 a.m. Licensed Practical Nurse Employee E4 confirmed the Albuterol Inhaler at bedside and the medication should not be left at bedside because he does not have a current order to self administer. 28 Pa. Code 211.12 (d)(1)(2)(3) Nursing Services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record reviews and interviews with staff, it was determined that the facility failed to review and revise the comprehensive care plan after a fall for two of six residents (Resident R52 and R62). Findings include: A review of facility policy Comprehensive Care Plans reviewed 1/18/24, indicated it is the policy of this facility to develop and implement a person-centered care plan for each resident. A review of the clinical record indicated Resident R52 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's (progressive mental deterioration, due to generalized degeneration of the brain), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and anxiety. A review of the Minimum Data Set (MDS- a mandated assessment of a resident's abilities and care needs) dated 3/5/24, indicated the diagnoses remained current. Review of Resident R52 nurse progress notes indicated she fell on the following dates:…

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 notify the physician of missed medication doses and failed to follow physicians orders for medication administration for one of five residents (Resident R61). Findings include: Review of facility policy Medication Administration dated 1/18/24, indicated medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. Review of facility policy Provision of Quality Care dated 1/18/24, indicated the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. Review of the facility Registered Nurse job description indicated the Registered Nurse (RN) will ensure that there is adequate stock of medications, supplies, and equipment and notifies appropriate…

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 provide care and services for a pressure ulcer for one of five residents (Resident R271). Findings include: Review of facility policy Pressure Injury Surveillance dated 1/18/24, indicated a system of surveillance is utilized for preventing, identifying, reporting, and investigating any new or worsened pressure injuries in the facility. Review of the clinical record indicated Resident R271 was admitted to the facility on [DATE]. Review of Resident R271's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/12/24, indicated diagnoses of end-stage renal disease (ESRD - an inability of the kidneys to filter the blood), history of falling, and diabetes (too much sugar in the blood). Review of Resident R271's admission Nursing assessment dated [DATE], indicated Resident R271 had a pressure ulcer to his sacral area (near the lower back). Review of Resident R271's…

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 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 one of three residents (Resident R45). Findings include: Review of the facility policy Use of Assistive Devices dated 1/18/24, indicated the policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity and include Orthotic equipment (a device that supports and stabilizes a joint or weakened body part). Review of the admission record indicated Resident R45 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/5/24, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), high blood pressure, and heart failure (heart doesn't pump blood as well as it should). Review of Resident R45's…

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, clinical record, and staff interview it was determined that the facility failed to acquire a physician's order correctly for the route of medication administration for two of three residents (Residents R21 and R38) receiving medications via a G-tube (tube placed into the stomach surgically). Findings include: Review of the facility policy Enteral Medication Administration dated 1/18/24, indicated to provide a safe, effective enteral medication administration process the nurse will verify medication order on the Medication Administration Record (MAR) with the medication label for the five rights (resident, drug, dose, route, and time). Review of the admission record indicated Resident R21 admitted to the facility on [DATE]. Review of Resident R21's Minimum Data Set (MDS- a periodic assessment of care needs) dated 3/27/24, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), high blood pressure, and heart failure (heart…

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 one of two residents reviewed (Resident R43). Findings include: Review of the facility policy Hemodialysis dated 1/18/24, indicated the center will coordinate and collaborate with the dialysis (the clinical purification of blood by dialysis as a substitute for the normal function of the kidney) facility to assure there is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. Review of the clinical record indicated Resident R43 admitted to the facility on [DATE]. Review of Resident R43's Minimum Data Set (MDS- a periodic assessment of care needs) dated 3/12/24, indicated the diagnoses of renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), high blood pressure, and atrial fibrillation…

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 three quarters reviewed (third quarter, July - September 2023). Findings include: Review of facility policy, Quality Assurance and Performance Improvement dated 1/18/24, indicated that the policy of the facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators on the outcomes of the care and quality of life and addresses all the care and unique services the facility provides. The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan. The QAA Committee shall be interdisciplinary and shall: a. Consist at a minimum of: i. The Director of Nursing ii. The Medical Director or his/her designee iii. At least three other members of the facility's staff, at least one of which must be 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, observations, and staff interviews, it was determined that the facility failed to provide a working call system for resident use to communicate their needs to staff for one of five residents (Resident R13). Findings include: The facility policy Call Lights: Accessibility and Timely Response dated [DATE], indicated the facility is adequately equipped with a call light at each residents' bedside to allow residents to call for assistance. Staff will report problems with a call light or the call system immediately to the supervisor and or/maintenance director and will provide immediate or alternative solutions until the problem can be remedied. Review of the admission record indicated 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 [DATE], indicated the diagnoses of coronary artery disease (narrow arteries decreasing blood flow to heart), heart failure (heart doesn't pump blood as well…

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, observation, and staff interview it was determined the facility failed to store drugs and biologicals in locked compartments in accordance with State and Federal laws for one of two medication carts (Second Floor Unit). Findings: Review of facility policy Medication Storage last reviewed 1/26/23, indicated all drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. During an observation on the Second Floor Unit on 12/7/23, at 2:18 p.m. revealed a medication cart was unlocked and accessible to residents. Staff were not visible in the area. During an interview on 12/7/23, at 12:19 p.m. Registered Nurse (RN) Employee E1 reported they were answering three call bells and left the cart unlocked. During an interview on 12/7/23, at 2:19 p.m. Registered Nurse Employee E1 confirmed 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.