Aristacare At Meadow Springs

Based on staff interview and review of facility documentation, it was determined that the facility failed to ensure COVID-19 vaccination status of employees was tracked and documented in accordance with regulatory requirements. Review of facility records revealed that the facility was unable to provide documentation demonstrating that it tracked and recorded the COVID-19 vaccination status of facility staff, including whether staff were fully vaccinated, partially vaccinated, had approved exemptions, or had pending vaccination status as required by regulation. Interview with the Infection Preventionist, Employee E12 on February 8, 2026, at approximately 1:40 p.m., Employee E12 confirmed the facility did not maintain a system to consistently track and document employees' COVID-19 vaccination status in accordance with regulatory requirements. 28 Pa. Code 201.18 (1) Management 28 Pa. Code 201.19(5) Personnel Records

Based on observations of the operations within the food and nutrition department, interviews with staff, it was determined that essential equipment used to maintain the air temperature in the main kitchen was not fully functioning. Observations of the main kitchen at 9:45 a.m. and 11:45 a.m., on February 8, 2026, revealed that all dietary staff were wearing knit hats and sweatshirts while working in the main kitchen. The dietary staff were reporting that it was extremely cold in the kitchen over the past two months. Interview with a dietary aide, Employee E 20 revealed that it was a necessity to wear extra layers of clothing everyday while preforming dietary tasks due to the air temperature inside the kitchen presenting an uncomfortable work environment. Observations of the vent above the dish machine revealed that cold air was free flowing into the main kitchen form the outdoor winter weather. The exhaust fan was not properly functioning by way of pulling air out of the kitchen. Observations of the air temperature throughout the main kitchen with the maintenance director, Employee…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of the physical environment throughout the facility, reviews of pest control visits and interviews with staff, it was determined that the facility failed to maintain an effective pest control program to ensure that the building was pest free, in one of three nursing units (200 nursing unit) and in the food and nutrition department.Findings include: Observations of the 200-nursing unit 10:15 a.m., on February 8, 2026, revealed that the double metal doors leading directly outside the building were not sealed properly. The threshold of the door allowed easy access for pests and rodents to enter the facility. A two-inch gap was observed at the bottom of the metal doors upon closing. Interview with the maintenance director, Employee E24 at 9:15 a.m., on February 9, 2026, confirmed the repairs necessary to prevent pests and rodent entry. Observations of the main kitchen of the food and nutrition department revealed that mice droppings were identified around the perimeter of the flooring throughout the dry food storage area. The dry food storage room contained a wall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of facility policy, it was determined that this facility failed to ensure that intravenous fluids were administered in a timely manner to one resident for whom the IV fluids have been ordered. (Resident R1)Findings include: Review of facility policy titled Insertion of Peripheral IV Catheter (undated) revealed the purpose of this procedure is to provide guidelines for a safe and aseptic insertion of an intravenous catheter for the admission of intravenous fluids and medications. The maximum number of venipunctures attempts on one resident is two per IV nurse. If unsuccessful after two attempts the facility must consult the contracted, IV company to insert a line. Review of facility's community IV (intravenous) company contract (undated) revealed, the IV vendor will ensure all nurses who are dispatched to perform placement of vascular access devices on patients identified by the facility are duly experienced and competent in iv access and licensed 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 observations, review of clinical record, and interview with staff, it was determined that facility failed to develop and implement a care plan related to hygiene care for one of three residents reviewed (Resident R2)Findings include: Review of facility policy 'Care Plans,' indicates that a care plan is developed in order to identify and maintain the highest level of functioning that a resident may be expected to attain. Each resident's comprehensive care plan has been designed to: incorporate identified problem areas.Review of Resident R2 (BIMS 99) clinical record on Wednesday, September 3rd, 2025, revealed a [AGE] year old male resident, admitted to facility on March 1, 2024, with medical diagnosis of quadriplegia, Parkinson's disease ( a disorder of central nervous system that affects movement, including tremors ), myocardial infarction, malnutrition, heart failure, chronic kidney disease - stage 3, gastrostomy status, dysphagia (difficulty swallowing), nontraumatic intracerebral hemorrhage.Further…

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

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for one of 28 residents reviewed for hospitalization. (Resident R100) Findings include: Review of nursing note for Resident R100, dated February 17, 2025, revealed that Resident R100 was transferred to hospital emergency room for low hemoglobin levels. Further review of Resident R100's clinical record revealed that there was no documented evidence that the resident and his representative were provided with a written notice of the facility bed-hold policy at the time of Resident R100's facility-initiated transfer to the hospital. Interview with the Nursing Home Administrator, Employee E1, on February 27, 2025, at 3:24 p.m. that Resident R100 and his representative were not provided with the bed hold policy, that included information explaining the duration of the bed-hold, bed hold reserve payment and permitting return 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 clinical record review,and review of policies and procedures, it was determined that the facility failed to update and revise a resident care plan realted to a wrist fracture for one of three residents reviewed. (Resident R85) Findings include: A review of the undated facility policy titled ongoing care plan updates revealed that it was the responsibility of the facility to develop and update the comprehensive care plan to include resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Clinical record review revealed a quarterly assessment dated [DATE] indicated that this resident was severely cognitively impaired. The assessment indicated that Resident R85 had impaired upper and lower extremities. The assessment also indicated that Resident R85 was totally dependent on staff for rolling left to right and chair to bed/bed to chair transfers. Clinical record revealed that this resident 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 observations, and interviews with staff, it was determined that the facility failed to provide appropriate treatment and services with a resident who exhibited a contracture of the hand for one of seven residents reviewed s. (Resident R85) Findings include: A review of the undated policy titled activities of daily living revealed that the facility was responsible for ensuring that residents receive assistance as needed for bathing, showering, dressing, grooming, betting out of bed, walking toileting and eating. The policy also indicated that special equipment would be provided as need for each resident. The policy said that the resident's care plan would reflect the appropriate level of care and personal preferences of each resident for activities of daily living. Clinical record review for Resident R85 revealed a quarterly Minimum Date Set (MDS- assessment of resident care needs) dated September 8, 2024 that indicated that Resident R85 had functional impairments of the upper and lower extremities. The assessment also indicated that this resident was fully dependent 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 observations of care and services, clinical record review, interview with staff, and reviews of policies and procedures, it was determined that the facility failed to ensure that for one of two residents reviewed with enteral nutrition that appropriate and timely treatment, to prevent complications of gastrojejunostomy tube feeding was implemented. (Resident R65) Findings include: A review of the undated policy titled Enteral Nutrition revealed that adequate nutritional support would be provided to residents that were unable to consume adequate nutritional intake by mouth. The policy indicated that enteral feeding orders would be written to ensure consistent volume infusion. The policy indicated that the dietitian was responsible for assessment of the gastrostomy or jejunostomy (surgical creation of an opening (stoma) through the skin at the front of the abdomen and the wall of the jejunum (part of the small intestine).tube feeding ) with the nurse. Clinical record review for Resident R65 revealed 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, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma informed care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for one of 28 residents sampled (Resident R 27) Findings include: A review of the clinical record revealed that Resident R27 was admitted to the facility on [DATE], with diagnoses to anxiety disorder, and post-traumatic stress disorder (PTSD) Interviewed with Social worker, Employee E15 on February 26, 2025, at 2:10, revealed that the resident R27's PTSD triggers is unknown by facility. Resident R27's current care plan on February 24, 2025, revealed a care plan for PTSD. Further review of the care plan did not address resident's actual diagnoses/condition of PTSD, identifying the resident's past experiences and possible triggers that may…

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

Based on clinical record reviews, interviews with staff and policies and procedure reviews, it was determined that the facility failed to ensure that one of six residents reviewed was being monitored and assesed for continued use of psychotropic medication. (Resident R19) Finding include: A review of the undated policy titled psychotropic medication revealed that it was the responsibility of the facility to ensure that psychotropic medications were being monitored and used properly. According to the policy psychotropic medications were drugs that effect brain activity with mental processing and behaviors. The policy indicated that as needed psychotropic medications were limited to fourteen days. The policy also indicated that if the prescriber wanted the as needed medication to be extended then the reason must be documented in the medical record and the duration of the as needed medication must also be indicated in the order for the psychotropic medication. Clinical record review for Resident R19 revealed a quarterly Minimun Data Set (MDS-an assessment of care needs) dated January…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of the food and nutrition services department, interviews with staff, it was determined that essential food service equipment and mechanical devices were not operating efficiently and effectively in the main kitchen. Findings include: Observations of the three compartment sink on February 24, 2025 revealed that the sink compartment used to sanitize the pots, pans, utencils, trays and cooking equipment was not holding water and the sanitizing solution. When tested the water and chemical were not at the proper concentration, according to the manufacturers recommendations. Upon further investigation the piping mechanism underneath the sinks were leaking water onto the floor. Interview with the Director of Dietary Services, Employee E13, on February 26, 2025 confirmed that this sink bay did not have the commercial sink drain and stopper to hold the chemical sanitizer and water concentration to effectively sanitize the pots, pans, utencils, trays and cooking equipment. Observations on February 24, 2025 of the metal doors leading directly from the main kitchen, 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 clinical records and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that care plan was updated to reflect changes in care needs for one of six residents reviewed (Resident R1). Findings include: A review of the facility policy titled Ongoing Care Plan Updates dated November 2028 revealed To develop a comprehensive care plan is developed that incorporates the resident's goals, preference, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. A review of the clinical file revealed that Resident R1 was admitted to the facility on [DATE]. Further examination of Resident R1's Minimum Data Set (MDS), dated [DATE], indicated that the Brief Interview for Mental Status (BIMS) was not recorded. This omission suggests that the resident was unable to participate in the assessment due to severe cognitive impairment. A review of the clinical progress notes…

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

Based on clinical record reviews, interviews with staff and and policy and procedure review, it was determined that the facility failed to ensure that physician's orders were follow for one of ten residents reviewed. (Resident R1) Findings include: A review of the facility policy titled administering medications August 18, 2022 revealed that medications and treatments were to be administrated in a safe and timely manner as prescribed by the physician. The policy also indicated that medications and treatments must be administered in accordance with the physician's orders, including any required time frame or parameters as specified by the physician. This policy said that if the drug was withheld the individual administering the medication was responsible to use the correct documentation on the MAR (Medication Administration Record) space provided for that drug. The policy indicated that the person administering the medication was responsible for recording the date and time of administration. A review of the policy titled physicians' medication orders dated August 18, 2024 revealed…

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

Based on clinical record review, interviews with staff and and policy and procedure review, it was determined that the facility failed to ensure that a doppler study was completed as ordered by the physician for one of ten residents reviewed. (Resident R1) Findings include: Clinical record review revealed that Resident R1 was readmitted to the nursing facility on August 16, 2024 with a diagnosis of replaced dislodged DOB Hoff tube (used for enteral feedings and medications for residents with swallowing problems), aspiration pneumonitis, and respiratory failure. Clinical record review revealed that the nurse practitioner's progress note dated August 22, 2024 indicated that Resident R1 was ordered a doppler (a test to estimate the blood flow through your blood vessels) study of the left arm due to swelling and pain. There was no doppler study of the left arm completed and available for review. Clinical record review revealed that the nurse practitioner ordered a STAT (emergency) doppler study for acute pain and swelling of the left arm for Resident R1 at 12:30 p.m., on August 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.

Based on clinical record reviews, review of physican orders and interviews with staff, it was determined that the facility failed to ensure complete documetation related to blood pressure for one of ten residents. (Resident R1) Findings include: A review of the facility policy titled administering medications August 18, 2022 revealed that medications and treatments were to be administrated in a safe and timely manner as prescribed by the physician. The policy also indicated that medications and treatments must be administered in accordance with the physician's orders, including any required time frame or parameters as specified by the physician. This policy said that if the drug was withheld the individual administering the medication was responsible to use the correct documentation on the MAR (Medication Administration Record) space provided for that drug. The policy indicated that the person administering the medication was responsible for recording the date and time of administration. Clinical record review revealed that Resident R1 was readmitted to the nursing facility on…

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

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for five of six residents reviewed (Residents R1, R2, R4, R5 and R6). Findings include: Clinical record review for Resident R1 revealed a nurse's note, dated May 3, 2024, at 8:10 p.m. which indicated that the resident had abnormal vital signs, including low blood pressure and high heart rate. The physician was notified and ordered for the resident to be transferred to a local hospital for evaluation. Continued clinical record review for Resident R1 revealed a nurse's note, dated June 15, 2024, at 10:01 a.m. which indicated that the resident was unresponsive with labored breathing. Emergency medical services were called and the resident was transferred to a local hospital for evaluation. Continued clinical record review for Resident R1 revealed a nurse's note, dated August 7, 2024, at 7:26 a.m. which indicated that the resident had two episodes of vomiting. 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 documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents with pressure ulcers received necessary treatments and services to promote healing, for one of six residents reviewed (Resident R1). Findings include: Review of Resident R1's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated June 21, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including neurogenic bladder (condition of bladder control problems dur to brain injury), paraplegia (paralysis of the legs and lower body), Parkinson's Disease (a progressive disorder of the nervous system that affects movement), spinal cord injury and muscle weakness. Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating that the resident was cognitively intact. Further review revealed that the resident was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that continence care was provided in a timely manner for one of six residents reviewed (Resident R1). Findings include: Review of Resident R1's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated June 21, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including neurogenic bladder (condition of bladder control problems dur to brain injury), paraplegia (paralysis of the legs and lower body), Parkinson's Disease (a progressive disorder of the nervous system that affects movement), spinal cord injury and muscle weakness. Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating that the resident was cognitively intact. Further review revealed that the resident was dependent for toileting and always incontinent of bowel and bladder.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of clinical records and interview with staff, it was determined that the facility failed to ensure that pressure ulcer prevention measures were followed as ordered by the physician for one of one resident with pressure ulcer reviewed. (Resident R69) Findings include: Review of facility's policy 'Prevention of Pressure Ulcers,' indicates that when in bed, every attempt should be made to 'float heels' (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by therapist and prescribed by the physician. Review of Resident R69's clinical records revealed past medical history of cerebral infarction, anoxic brain damage, persistent vegetative state, anemia, long-term anticoagulant use, gastrostomy status, and ventilator status. Review of February 2024 physican orders revealed an order revised on February 8, 2023 to wear prevalon boots to BLE (bilateral legs) at all times except for hygiene or skin checks. Continued review of physician orders revealed another order dated April 15, 2022 to off load heels with…

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

Based on review of facility policy, observations, record review, and staff interviews, it was determined that the facility failed to provide respiratory care services consistent with professional standards of practice for three of 34 residents reviewed. (Residents R38, Resident R41, Resident R390). Findings Include: Review of facility policy Disposable Equipment Changes undated states, Policy Statement- Respiratory care disposable equipment changes are consistent with manufacturer's recommendations, CDC guidelines and per Respiratory Care Clinical Practice Guidelines. Purpose-To establish guidelines for consistent changes of disposable equipment. To limit the occurrence of equipment related infection. To assure disposable equipment maintains both its physical integrity and proper function. Please note: All equipment (disposable/Non-disposable) including: nasal cannulas, aerosol tubing, nebulizer caps and tubing, treatment nebs, BIPAP/CPAP tubing and masks, must be stored in a clean set-up bad when not in use (between usage). Review of facility policy titled Tracheostomy Care undated…

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

Based on observation, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to hot water temperatures which resulted in Immediate Jeopardy situation. Findings include: Review of the job description of the Nursing Home Administrator (NHA) revealed that, The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our residents at all times. The job description of the Director of Nursing (DON) revealed that, The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be director by the Administrator and the Medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, it was determined that the facility failed to ensure that residents records were accurately documented for one of 27 residents reviewed (Resident R69) Findings include: Review of Resident R69's clinical records revealed that the resident was [AGE] year old female with past medical history of cerebral infarction, anoxic brain damage, persistent vegetative state, anemia, long-term anticoagulant use, gastrostomy status, and ventilator status. Resident R69's physician is Employee, E38. The resident was admitted on [DATE]. Review of R69's progress notes revealed a pulmonary progress note dated March 14, 2024 at 6:30 pm, completed by physician, Employee E39, which was not the resident's physician. The progress notes stated seen and examined 3/14/24 [AGE] year old male admitted in December after falling from bed. Found to have C4-5 fracture and underwent surgery as listed below. He put placed back on the vent due to pneumonia . Interval Recommendation - 2/16/24 Continue vent support…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and clinical record review, observations, and staff interviews, it was determined that the facility failed to maintain an effective infection control and prevention practice during medication administration for two of 27 residents reviewed. (Resident R6 and Resident R90) Findings include: Review of facility's policy title Administering Medications, revealed that medications shall be administered in safe and timely manner and as prescribed. No medications are kept on top of the cart. During observation of medication administration with Licensed nurse, Employee E36, on April 17, 2024 at 9:37 a.m. revealed an un-capped and pre-filled insulin syringe on top of cart. Employee E36 was observed carrying the un-capped insulin syringe to Resident R69's room and place it on bed side table. Employee E36 was observed to attempt to open new Lacosamide oral solution 10mg/ml bottle with her keys. Further observations revealed Employee E36 attempting to collect urine from Resident R69's foley by placing…

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