Maple Winds Healthcare and Rehabilitation, LLC

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement an individualized care plan for two of 21 residents reviewed (Residents 24 and 36).Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated May 7, 2026, revealed that the resident was cognitively intact and received an antidepressant medication.Physician's orders for Resident 24, dated April 30 and May 11, 2026, included an order for the resident to receive 5 mg of buspirone every morning and bedtime for depression and then 2.5 mg of buspirone every morning and night for depression.Medication Administration Records (MAR's) for Resident 24 for May 2026, revealed the resident received buspirone from May 1 through May 18, 2026.There was no documented evidence that a care plan was developed to address Resident 24's depression and use of buspirone.Interview with the Director of Nursing on May 18, 2026, at 12:06 p.m. confirmed that the resident did not have a care…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for four of 21 residents reviewed (Residents 13, 16, 24 and 52).Findings include: A facility policy for Care Plan Revisions Upon Status Change dated August 26, 2025, indicated that the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated February 15, 2026, indicated that the resident was cognitively intact, did not receive an anticoagulant, and had diagnoses that included high blood pressure and dementia. Current physician's orders for Resident 13 included an order to receive 5 milligrams (mg) of apixaban (anticoagulant) twice a day for atrial fibrillation (irregular heartbeat),.A review of the Medication Administration Records (MAR's) for Resident 13 for May 2026 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.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident had dentures in place for breakfast for one of 21 residents reviewed (Resident 36). Findings include: The facility's policy regarding care of dentures, dated August 26, 2025, revealed that nursing staff will provide denture care. If a resident is unable to care for their own dentures, dentures will be cleaned for them during routine oral care. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 36, dated May 6, 2026, revealed that the resident was cognitively intact, required assistance with daily care needs and had a diagnosis of malnutrition. A physician's order for Resident 36, dated May 15, 2026, included an order for the resident to receive a regular diet, mechanical soft texture with nectar consistency liquids. An admission assessment for Resident 36, dated May 1, 2026, revealed that the resident had upper and lower dentures. Interview with the…

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

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident environment was as free of accident hazards by failing to complete safety assessments for air mattress use for three of 21 residents reviewed (Residents 4, 6, 24).Findings include: The facility's policy regarding air mattresses, dated August 26, 2025, indicated that the air mattress would be used in accordance with evidence-based practice for residents with or at risk for pressure injuries. Air mattresses would be chosen by matching the potential therapeutic benefit with the resident's specific situation. Considerations for utilizing air mattresses included: medical condition, size and weight, mobility and activity levels, need for moisture control or shear reduction, presence of pressure injuries, risk of developing a pressure injury or at high risk for additional pressure injuries, pain and discomfort, and an excessive amount of penetration of the surface. Air mattresses would be utilized in accordance 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 clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure nephrostomy output was monitored for one of 21 residents reviewed (Resident 4) who had a nephrostomy tube (a flexible tube inserted into the kidney to drain urine), and failed to ensure that a follow up appointment was kept for one of 21 residents reviewed (Resident 5).Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated April 11, 2026, revealed that the resident was cognitively intact, had limited range of motion of the lower extremities, required assistance from staff for daily care needs, had nephrostomy tubes (thin catheter inserted through the skin into the kidney to allow urine to drain directly into a collection bag outside the body), and diagnoses that included renal disease and obstructive uropathy (blockage in the urinary system).Physician's orders, dated October 23, 2025, included orders for staff to empty the resident's bilateral nephrostomy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 21 residents reviewed (Resident 52) who had a feeding tube.Findings include: The facility policy regarding enteral tube feedings, dated August 26, 2025, indicated that prior to the administration of the tube feeding, staff were to verify the placement of the feeding tube and were to document the verification of the tube placement. The tube feed was to be flushed before and after feedings and medications. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 52, dated April 17, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care tasks, and had a feeding tube. Physician's orders for Resident 52, dated April 14, 2026, included orders for the resident to receive Jevity 1.5 (a tube feeding formula) 237 milliliters five times a day. Observations for Resident 52 tube feed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and clinical records, as well as observations and staff interviews, it was determined that the facility failed to administer a resident's continuous oxygen as ordered for one of 21 residents reviewed (Resident 12). Findings include: The facility's policy regarding oxygen therapy, dated August 26, 2025, indicated that oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12 dated April 30, 2026, indicated that the resident was cognitively impaired, required supervision with daily care needs, received oxygen therapy, and had a diagnosis of coronary artery disease (CAD-a disease that limits blood flow to the heart caused by plaque buildup in the arteries).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 21 residents reviewed (Resident 17). Findings include: A quarterly MDS assessment for Resident 17, dated March 20, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs, had pain occasionally, received as needed pain medications, was taking an opioid medication (a controlled medication used to treat pain), and had diagnoses that included fibromyalgia (chronic condition causing pain in muscles and joints throughout the body). Physician's orders for Resident 17, dated January 27, 2026, included an order for the resident to receive 50 mg of Tramadol (opioid medication) every four hours as needed for moderate to severe pain. Review of Resident 17's Medication Administration Record (MAR) for April 2026, revealed that the resident received 50 mg of Tramadol on April 8 at 7:39 a.m.; April 9 at 7:10 a.m.; April 10 at 6:40 a.m.; April 11 at 6:12 p.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.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include: The facility's deficiencies and plan of corrections for an annual survey ending July 2, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending May 18, 2026, identified repeated deficiencies related to accurate MDS assessments, creation of care plans, revision of care plans, quality care, safety/accidents, bowel/bladder incontinence and indwelling urinary catheters, maintenance of IV catheters, narcotic accountability, and infection control. The facility's plan of correction for a deficiency regarding accurate MDS assessments, cited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 21 residents reviewed (Resident 52). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was offered and/or received the influenza immunization for one of 21 residents reviewed (Resident 24) and failed to ensure that each resident was offered and/or received the pneumococcal immunization for five of 21 residents reviewed (Residents 1, 5, 24, 48 and 52). Findings include: The facility's policy regarding the influenza vaccine, dated August 26, 2025, indicated that between October 1 and March 31 each year, the influenza vaccine shall be offered to residents unless the vaccine is medically contraindicated or the resident has already been immunized during that time. For those who receive the vaccine, the date of the vaccine, lot number, expiration date, person administering, and the site of the vaccination shall be documented in the resident's medical record. A resident's refusal of the vaccine shall be documented on the informed consent form and placed in the resident's medical chart. The infection preventionist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility assessment and employee education records, as well as staff interviews, it was determined that the facility failed to ensure that nurse aides completed the required annual education for three of five nurse aides reviewed (Nurse Aides 4, 6, and 7).Findings include: The facility assessment regarding education, dated January 2026, indicated that all personnel, including manager, staff (both employees and those who provide services under contract), and volunteers, indicated that the nurse aides would receive their necessary education credits annually. Review of the employee education file for Nurse Aide 4 revealed that there was no documented evidence of twelve hours of required education completed between 2024-2025. Review of the employee education file for Nurse Aide 6 revealed that there was no documented evidence of twelve hours of required education completed between 2024-2025. Review of the employee education file for Nurse Aide 7 revealed that there was no documented evidence of twelve hours of required education completed between 2024-2025.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, and staff interviews, it was determined that the facility failed to ensure that food stored in the kitchen and dry storage room was dated once opened. Findings include: The facility policy regarding food storage, dated March 12, 2025, revealed that any food item once opened should be labeled with an open date. Observations in the dry storage room on June 30, 2025, at 8:53 a.m. revealed that there was one 10-pound bag of pasta that was opened and not dated with an open date. Observations in the kitchen refrigerator on June 30, 2025, at 9:01 a.m. revealed two opened and undated 5-pound bags of cheese, one with parmesan and the other with a mixture of cheddar and mozzarella. Observations in the kitchen on June 30, 2025, at 9:07 a.m. revealed that there was approximately ten pounds of flour and twenty-five pounds of rice that were opened and not labeled with an open date. Interview with the Dietary Manager and Director of Nursing on June 30, 2025, at 8:45 a.m. and 11:32 a.m. respectively, confirmed that all open food items in the kitchen should be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required timeframe for 10 of 35 residents reviewed (Residents 14, 26, 34, 43, 44, 139, 140, 141, 142, 143). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that for admission MDS assessments, the assessment completion date was to be no later than the resident's admission date plus 13 calendar days. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated May 12, 2025, revealed that the resident was admitted on [DATE]. 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.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for one of 35 residents reviewed (Resident 13). Findings include: The facility's policy regarding care plans, dated March 12, 2025, indicated that each resident will have an individualized interdisciplinary plan of care in place. The comprehensive care plan will be reviewed and revised on a quarterly basis, with a significant change in condition, on re-admission, and as needed or requested by the resident and/or resident's representative. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 13, dated April 9, 2025, revealed that the resident was understood, could understand others, and had diagnoses that included obstructive uropathy (a condition where there is a blockage in the urinary tract, preventing normal urine flow). A care plan for the resident, dated February 11, 2025, revealed that the…

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

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure urinary output was monitored for one of 35 residents reviewed (Resident 1) who had an indwelling urinary catheter, and failed to ensure proper incontinent care was completed for one of 35 residents reviewed (Resident 13). Findings include: The facility's policy regarding urinary output, dated March 12, 2025, revealed that the volume of urine output was to be documented in the resident's chart or electronic medical record. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 24, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care tasks, had an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine), and had diagnoses that included neurogenic bladder (a lack of bladder control due to a brain, spinal cord, or nerve condition). Physician's orders for Resident 1, dated May 26, 2025,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that intravenous catheters were flushed according to facility policy and failed to ensure that physician's orders for the care and maintenance of intravenous catheters were obtained for two 35 residents reviewed (Residents 9, 12). Findings include: The facility's policy regarding midline (a thin, flexible tube inserted into a large vein in the upper arm to administer medication or fluids intravenously) maintenance and care, dated March 12, 2025, indicated that staff was to change the transparent dressing every week or as needed if soiled, damp and/or loose. Staff was flush the line according to the physician's orders. The policy regarding flushing the peripheral intravenous access (the insertion of a short, flexible catheter into a peripheral vein, typically in the hand or arm, to deliver medications, fluids or other therapies directly into the bloodstream), dated March 12, 2025, indicated that the following regimen should be used when flushing 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the physician and the resident's responsible party regarding a change in condition for one of 35 residents reviewed (Resident 2). Findings include: The facility's policy regarding changes in a resident's condition or status, dated March 12, 2025, revealed that physicians, responsible family members or legal representatives would be notified as soon as possible of any changes in the resident's condition. A quarterly admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 31, 2024, revealed that the resident was cognitively intact and had diagnoses that included diabetes, congestive heart failure, and chronic obstructive pulmonary disease. A review of Resident 2's care plan, dated November 1, 2023, indicated that the resident had a history of acute (sudden onset) respiratory failure. A nursing note for Resident 2, dated November 13, 2025, at 6:17 p.m. revealed that when staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and facility grievance/complaint logs, as well as staff interviews, it was determined that the facility failed to follow its grievance policies regarding maintaining a log of all grievances received for one of 35 residents reviewed (Resident 13). Findings include: The facility's policy regarding grievances/complaints, dated March 12, 2025, indicated that a concern form is initiated when a concern/grievance is brought forward by a staff, family, responsible party and/or resident. After obtaining necessary information from the resident, family, responsible party and/or staff the concern form is completed and submitted to the Social Services Director or the Administrator who then distributes it to the appropriate depart head(s). The Social Service Director will log the form into a concern and grievance log. The Social Services Director will maintain a concern and grievance log as well as ensure concerns/grievances are completed and followed up with in a timely manner including effectiveness. Results of concerns/grievances will be maintained for a minimum 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and the resident's representative, in writing regarding the reason for transfer to the hospital, to ensure that a bed-hold notice was provided to the resident's responsible party and that the ombudsman was notified of the transfer to the hospital, for three of 35 residents reviewed (Residents 2, 19, 38), and failed to complete a post discharge summary for one of 35 resident's reviewed (Resident 37) Findings include: The facility's policy regarding bed-holds and returns, dated March 12, 2025, indicated that residents and/or representatives are informed (in writing) of the facility and bed-hold policies. An original is to be placed in the resident chart and one given to the family. The facility's policy regarding physician discharge summary revealed that when a resident is discharged the physician will complete and sign a discharge summary that includes the diagnosis,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of 35 residents reviewed (Residents 1, 25). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2024, revealed that Section N0415G1 Diuretic Medications was to be coded if the resident took the medication during the seven-day look-back period, and Section N0415K1 Anticonvulsant Medications was to be coded if the resident took the medication during the seven-day look-back period. Physician's orders for Resident 1, dated May 21, 2025, included an order for the resident to receive 20-25 milligram (mg) of Lisinopril-hydrochlorothiazide (a combination antihypertensive-diuretic medication used to lower blood pressure) in the morning for hypertension (high blood pressure). Review of the Medication…

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

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of 35 residents reviewed (Resident 9). Findings include: A facility policy for Care Plans, dated March 12, 2025, indicated that the resident and his or her representative were encouraged to participate in the development and implementation of the resident's person-centered care plan. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 9, dated April 10, 2025, revealed that the resident was cognitively intact, required extensive assistance from staff with daily care tasks, and received an anticoagulant, antiplatelet, and diuretic medication. Physician's orders for Resident 9, dated September 9, 2024, included an order for the resident to receive 5 milligrams (mg) of Apixaban (anticoagulant-used to prevent blood clots) by mouth every morning 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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of 35 residents reviewed (Resident 12). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 20, 2025, revealed that the resident was understood, and could usually understand others. Physician's orders for Resident 12, dated May 20, 2025, included an order for the resident to receive one gram (gm) of Meropenem (an antibiotic to treat a variety of serious bacterial infections) intravenously (a medical process that administers fluids, medications and nutrients directly into a person's vein) every eight hours for a urinary tract infection for seven days (a total of 21 doses). Review of Resident 12's Medication Administration Records (MARs) for May 2025 revealed that staff documented as administering 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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as possible by failing to ensure that fall/injury prevention interventions were in place for one of 35 residents reviewed (Resident 9). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 9, dated April 10, 2025, revealed that the resident was cognitively intact, required extensive assistance from staff with daily care tasks, and had limited range of motion to her lower extremities. The resident's care plan, dated June 19, 2025, revealed that the resident was at risk for falls and indicated that fall mats were to be at bedside. A nursing note for Resident 9, dated June 13, 2025, at 2:50 a.m., revealed that the resident was found lying on the floor on the left side of her bed. New interventions included placing her bed in the lowest position and bilateral fall mats. Observations of Resident 9 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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 35 residents reviewed (Resident 25). Findings include: The facility's policy regarding disposal of narcotics, dated March 12, 2025, indicated that controlled/narcotic medications were to be destroyed in the presence of tow licensed nurses. The two nurses would count together the remaining amount of controlled/narcotic medications to be destroyed. Two nurses would sign and date the Control Drug Record upon witnessing the destruction of the controlled/narcotic medications, logging the amount of medications destroyed. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated April 22, 2025, revealed that the resident was cognitively impaired, received pain medication routinely and as needed, and received an opioid (a controlled pain medication). Physician's orders, dated April…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for one of 35 residents reviewed (Resident 25) who were receiving hospice services. Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated April 22, 2025, indicated that the resident was cognitively impaired, received hospice services, and had a diagnosis of cancer. Physician's orders and a care plan for Resident 25, dated April 15, 2025, included an order for the resident to be treated by hospice (end-of-life services) for basal cell carcinoma (skin cancer) of the left upper limb. As of July 1, 2025, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained updated hospice nurse aide or registered nurse charting. The last hospice nurse aide charting located on 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 the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) surveys ending June 5, July 11, and December 26, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending July 2, 2025, identified repeated deficiencies related to care plan revisions; providing quality care; ensuring that the resident's environment was free from accident hazards; maintaining intravenous catheters; preventing issues with the accountability of controlled medications (drugs with the potential…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and attendance records for the facility's Quality Assurance Committee, as well as staff interviews, it was determined that the facility failed to ensure that all required members of the Quality Assurance Committee attended quarterly meetings. Findings include: The facility's policy for Quality Assurance and Performance Improvement, dated March 12, 2025, revealed that meetings would be held at least quarterly and would include the Nursing Home Administrator, Director of Nursing, all department heads, a community member, and the Medical Director. Review of the attendance records for the facility's Quality Assurance Committee meetings revealed that the Medical Director did not attend any meetings that were held during the first quarter of 2025. Interview with the Director of Nursing on July 2, 2025, at 2:30 p.m. confirmed that the Medical Director did not attend meetings of the Quality Assurance Committee that were held during the first quarter of 2025. 28 Pa code 201.18(b)(3) Management.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand washing techniques were used during medication administration for three of three residents observed (Residents 2, 29, 45). Findings include: The facility's policy regarding hand hygiene, dated March 12, 2025, indicated that all employees were to follow the hand washing procedure, which included hand sanitizing, before preparing or handling medications, and after removing gloves. Observations during the medication pass in A hall on July 2, 2025, at 8:33 a.m. revealed that Licensed Practical Nurse 1 prepared Resident 45's medications and administered them. Without sanitizing her hands, she donned gloves and entered Resident 29's room and took the resident's blood pressure. She doffed her gloves and without hand sanitizing she prepared and administered Resident 29's medications. She then went to Resident 2's room and donned gloves and checked the resident's blood sugar. She doffed her gloves and without hand sanitizing she prepared the…

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

Based on review of facility policies, clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to ensure that peripherally-inserted central catheters (PICC lines) site dressings were changed per physician's orders for one of six residents reviewed (Resident 2). Findings include: The facility's policy regarding PICC line maintenance and care, dated May 6, 2024, indicated that staff are to change the dressing every week. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 3, 2024, revealed that the resident was always understood, always understood others, was cognitively impaired, required assistance from staff for daily care needs, and that he was receiving intravenous medications (IV). Physician's orders for Resident 2, dated December 18, 2024, included and order for the resident to have the PICC line dressing changed every week. Review of Resident 2's Medication Administration Record (MAR), dated December 2024, revealed that staff…

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

Based on review of facility policy, clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to maintain resident dignity for two of six residents reviewed (Residents 2, 6). Findings include: The facility's policy regarding Resident Rights, dated May 6, 2024, revealed that the facility would protect and promote the rights of each resident, particularly those rights that pertain to a dignified existence. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 3, 2024, revealed that the resident was always understood, always understood others, was cognitively impaired, and required assistance from staff for daily care needs. Observations of Resident 2 on December 26, 2024, at 8:36 a.m. revealed that the resident had no curtain or blind covering the window to the outside. His bed was on the window side of the room and the window faced the facility's main parking lot. A significant change MDS assessment for Resident 6, dated December 16,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interviews, it was determined that the facility failed to ensure personal privacy for one of six resident reviewed (Resident 2). Findings include: The facility's policy regarding Resident Rights, dated May 6, 2024, revealed that the facility would protect and promote the rights of each resident, particularly those rights that pertain to a dignified existence. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 3, 2024, revealed that the resident was always understood, always understood others, was cognitively impaired, and required assistance from staff for daily care needs. Observations of Resident 2 on December 26, 2024, at 8:36 a.m. revealed that the resident had no curtain or blind covering the window to the outside. His bed was on the window side of the room, and the window faced the facility's main parking lot. Interview with Resident 2 on December 26, 2024 at 8:36 a.m. revealed that he has asked for a curtain or…

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

Based on review of facility policies, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that a thorough investigation was completed for an injury of unknown origin, to rule out that abuse and/or neglect were involved for one of five residents reviewed (Resident 5). Findings include: The facility's policy regarding abuse and neglect, dated May 6, 2024, indicated that the Director of Nursing/designee conducts the investigation. Reviews the accident/incident report; obtains written statements of staff assigned to the resident for the shift during which the allegation is noted, and 24 hours prior if indicated; and interviews witnesses, if any, and obtains statements. The facility's policy regarding incident/accident reporting, dated May 6, 2024, indicated that in the case of an incident or injury of unknown etiology, an investigative report of injury unknown origin and investigative report of skin tear/bruise of unknown etiology are completed, as needed. All employees assigned to the resident involved in 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 manufacturer's directions for use, investigative reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free from accident hazards as possible by failing to follow the manufacturer's directions for use of a high-back reclining wheelchair for one of three residents reviewed (Resident 1), resulting in a fall. Findings include: Operation instructions for the Medline Standard Manual Wheelchairs, dated December 30, 2021, revealed that to ensure safety in using this Medline wheelchair, all warnings and safety information and all instructions must be followed. Failure to do so may result in serious bodily injury or damage to the chair. Recliner models only: DO NOT use the recliner wheelchair without the anti-tip devices installed. Anti-tippers MUST be always attached, and both must be adjusted to the same height. Ensure the anti-tippers are secured as evidenced by the spring buttons fully protruding out of the holes. Anti-tippers (included with select models): Rear…

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

Based on review of the facility's written menus, as well as observations and staff interviews, it was determined that the facility failed to follow their planned menu. Findings include: A facility's policy regarding menu management, dated May 6, 2024, revealed that menus were to be posted on menu boards located in the dining room and hallway. Temporary changes to the menu will be posted daily on the menu boards. To ensure consistency, all meals served will strictly adhere to the pre-approved menus. The facility's written and posted weekly menu for the lunch meal on June 3, 2024, revealed that the residents were to receive bread with margarine. Observations during the lunch meal on June 3, 2024, at 12:08 p.m. revealed that the residents did not receive bread or margarine for the lunch meal. Interview with the Dietary Manager on June 3, 2024, at 12:58 a.m. revealed that a new cook eliminated the bread from the menu for lunch and she did not know why, but the residents should have been provided bread and margarine with their meal. 28 Pa. Code 211.6(a) Dietary Services. 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for were followed for three of 27 residents reviewed (Residents 11, 27, 35) and failed to ensure that neurological checks were completed following an unwitnessed fall for one of 27 residents reviewed (Resident 13). Findings include: A facility policy related to physician's orders, dated May 6, 2024, indicated that medications, treatments, and care is provided to residents upon written and/or verbal order. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated May 2, 2024, revealed that the resident was understood and could understand others, required assistance with daily care needs, received insulin, and had diagnoses that included diabetes. Physician's orders for Resident 11, dated October 18, 2023, included an order for the resident to receive 44 units of Glargine insulin (a long-acting insulin) subcutaneously (injected just under the skin)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for four of 27 residents reviewed (Residents 2, 11, 29, 34). Findings include: The facility's policy regarding medication administration, dated May 6, 2024, revealed that all medications were ordered, acquired, and administered in accordance with Pennsylvania State Regulations as governed by the Centers of Medicare and Medicaid Services, and in accordance with all policies and procedures of the facility. If a medication was to be administered at a specific time, the specific time may be based upon resident's choice. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 7, 2024, revealed that the resident was understood and could understand others, had complaints of pain rated as a 5 out of 10 on a pain scale, and was receiving controlled pain medication. A care plan,…

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

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to respond timely to pharmacy recommendations for four of 27 residents reviewed (Residents 3, 11, 35, 36) and failed to obtain completed pharmacy recommendations for physician review for two of 27 residents reviewed (Residents 10, 29). Findings include: The facility's policy for drug regimen review, dated May 6, 2024, indicated that a drug regimen review is performed by a licensed pharmacist for every resident each month. The pharmacist will report any medication irregularities and recommendations to the attending physician on a pharmacy review sheet. The physician will respond to the pharmacist's recommendation on the review sheet, and it will be returned to the facility to be acted upon. The review sheet will be filed in the resident's chart in the physician progress section and will be kept in the chart for one full year. A quarterly Minimum Data Set (MDS) (assessment of a resident's abilities and care needs) for Resident 3, dated April 12, 2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, and staff interviews, it was determined that the facility failed to provide reasonable accommodation of a resident's needs by failing to ensure that the call bell was within reach for one of 27 residents reviewed (Resident 35). Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated March 8, 2024, indicated that the resident was sometimes understood and could sometimes understand, was cognitively impaired, and required maximum assistance for transfers and toileting. The resident's current care plan indicated that the resident had decreased mobility and that staff were to ensure the call bell was within reach, and the resident was to have her bed and chair alarms on and operational while she was in her bed or chair. Observations of Resident 35 on June 3, 2024, at 10:31 a.m. revealed that the resident was lying in bed, and the call bell was in her nightstand drawer with the drawer closed and was not within her reach. The resident's bed alarm…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and clinical records, as well as staff interviews, it was determined that the facility failed to address and maintain advance directives as part of the clinical record for one of 27 residents reviewed (Resident 29). Findings include: The facility's policy regarding advance directives (instructions regarding the provision of health care and life sustaining measures when the resident is incapacitated), dated May 6, 2024, indicated that upon admission residents and/or their responsible party are asked if an advanced directive or living will exists. If an advanced directive or living will exists, it is reviewed and placed in the resident's chart. If an advanced directive or living does not exist, the resident and/or their responsible party are asked if they wish to complete one. Advanced directives are reviewed with the residents as needed by social worker and acknowledgment forms are filed in the resident's medical record. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that the status of nursing licenses was checked with the State Board of Nursing for one of two nurses reviewed (Licensed Practical Nurse 2) and failed to complete a Nurse Aide Registry verification for one of three nurse aides reviewed (Nurse Aide 3). Findings include: The facility's policy regarding abuse, neglect or mistreatment, dated May 6, 2024, indicated that potential employees must pass the pre-employment screening process to be hired at the facility. Potential employees must pass a criminal background check inquiring for a history of abuse, neglect, or mistreatment of residents as defined by the requirements of federal regulations. This search includes attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries. The personnel file for Licensed Practical Nurse 2 revealed a start date of February 10, 2019. However, there was no documented evidence until July…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for three of 27 residents reviewed (Residents 13, 29, 43). Findings include: A quarterly Minimum Data Set (MDS) (assessment of a resident's abilities and care needs) for Resident 13, dated May 14, 2024 revealed that the resident was able to make herself understood and understood others, was moderately cognitively impaired, required assistance from staff for personal care needs, and had a mechanically altered therapeutic diet. A care plan for Resident 13, dated June 21, 2022, revealed that she had an impaired nutritional status and required a mechanically altered therapeutic diet with thickened liquids that was to be provided as ordered. Physician's orders for Resident 13, dated May 9, 2024, included orders for the resident tor receive a carbohydrate controlled, mechanically soft textured diet, with thin consistency liquids, and may have salads per speech therapy. 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.

Based on review of Pennsylvania's Nursing Practice Act, clinical records, and staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident after a fall for one of 27 residents reviewed (Resident 13). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated May 14, 2024, revealed that the resident was able to make herself understood and understood others, was moderately cognitively impaired, and required assistance from staff for personal care needs. A licensed practical nurse's note 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 facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to follow treatment recommendations for one of six residents reviewed (Resident 6). Findings include: A facility policy regarding pressure ulcer prevention and management, dated May 6, 2024, revealed that a wound care nurse consult would include assessment and finding, which may include stage, measurements, appearance, and treatment recommendations in the consult report. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated March 27, 2024, indicated that the resident was usually understood and could usually understand others, was dependent on staff for care, and was at risk for a pressure ulcer (skin breakdown caused by prolonged, unrelieved pressure). Physician's orders for Resident 6, dated May 15, 2024, included an order for the resident to have his right heel cleansed, patted dry, Medihoney (wound ointment) applied, then covered with bordered gauze once daily and as needed 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 clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that contracture management services were provided as care planned for one of 27 residents reviewed (Resident 25). Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated March 20, 2024, revealed that the resident was able to make herself understood and was able to understand others, was dependent on staff for her daily care needs, and had diagnoses that included hemiplegia (muscle weakness or partial paralysis on one side of the body). Occupational Therapy orders for Resident 25, dated January 10, 2024, included an order for the resident to have passive range of motion (when someone physically moves or stretches a part of your body) to all joints in her left hand twice a day. A care plan for Resident 25, dated May 1, 2024, revealed that the resident was on a restorative nursing program for range of motion. Nursing tasks for Resident 25 included that the…

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

Based on observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart. Findings include A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 244, dated May 28, 2024 revealed that the resident understood others and was understood, was cognitively intact, required assistance from staff for personal care needs, and has a diagnosis of gout (a build up of uric acid that causes pain and inflammation). Observations on June 3, 2024, at 10:49 a.m. revealed that there was a round white pill on the floor of Resident 244's room. Physician orders for Resident 244, dated May 13, 2024, included an order for the resident to be administered 100 milligrams (mg) of Allopurinol in the morning for gout. Interview with Licensed Practical Nurse 5 on June 3, 2024, at 10:59 a.m. confirmed the white pill with 349 IJ was identified as Allopurinol (a medication used to treat gout), and Resident 244 was currently prescribed the medication. Interview 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 facility policy, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 27 residents reviewed (Resident 13). Findings include: The facility's policy regarding nursing documentation, dated May 6, 2024, revealed that all documentation confirms that care was provided. Documentation identifies the resident's status, clinical findings and interventions. It is the staff's responsibility in documentation, which acts as proof that care was provided. All documentation was to be done in the electronic record Point Click Care (PCC). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated May 14, 2024, revealed that the resident was able to make herself understood and understood others, was moderately cognitively impaired, and required assistance staff for personal care needs. A licensed practical nurse's note for Resident 13, dated February 21, 2024, indicated that she was lying on her fall…

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

Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending June 1, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending June 5, 2024, identified repeated deficiencies related to failure to develop resident care plans, failure to provide quality of care, failure to maintain complete and accurate medical records, and failure to maintain a complete and accurate accounting of controlled medications. The facility's plans of correction for deficiencies regarding developing and implementing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and personnel files, as well as staff interviews, it was determined that based on nurse aides' hire dates, the facility failed to ensure that nurse aides completed at least 12 hours of inservice education for one of five nurse aides reviewed (Nurse Aide 6). Findings include: The facility's policy regarding nurse aide inservice training, dated May 6, 2024, indicated that the facility will maintain an ongoing educational program for the development and improvement of skills of the facility's personnel, including at a minimum, annual in-service training. Certified Nursing Assistants are required to complete at a minimum 12 hours total annually. Nurse aide education records revealed that based on their hire dates Nurse Aide 6 did not have at least 12 hours of education annually as follows: Nurse Aide 6's hire date was May 18, 2018, and inservice records revealed that she had no annual education completed between May 2022 and May 2024. Interview with the Human Resources Director on June 5, 2024, at 10:40 a.m. confirmed that Nurse Aide 6 did not have 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident and/or the resident's representative at the time of transfer for three of three residents reviewed (Residents 1, 2, 3). Findings include: The facility's policy regarding bed holds (holding a resident's bed while the resident is absent from the facility for hospitalization), dated October 6, 2023, indicated that the admission director/designee will contact the resident/resident's representative following a facility-initiated transfer to an acute care facility or hospital. The original copy of the facility's bed-hold policy was to be placed in the resident's chart and the copy can be given to the family. This can be in person or sent via email. If the representative is present, then they can be informed at that time. Then document in the resident's electronic medical record that the resident/representative was notified either via phone call or in person and received a copy and the…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to permit the readmission of a hospitalized resident without providing evidence that the facility was not able to meet the resident's needs for one of three residents reviewed (Resident 1). Findings include: The facility's policy regarding notice requirements for transfer/discharge of a long-term resident, dated October 6, 2023, indicated that the facility must permit each resident to remain in the facility and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident, or the health of individuals in the facility would otherwise be endangered. The facility must also be sure to document the danger that failure to transfer or discharge would pose. An admission Minimum Data Set (MDS) assessment (a mandated assessment of…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for one of three residents reviewed (Resident 1). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 27, 2023, revealed that the resident was understood, understands, and had a diagnosis which included osteomyelitis (a serious infection of the bone that can be either acute or chronic) and aquired absence of the right great toe. A wound healing center note for Resident 1, dated January 2, 2024, revealed that staff was to leave the dressing on the resident's foot for three days and then apply betadine dressings daily. Review of Resident 1's Treatment Administration Record (TARs) for January 2024 revealed that staff completed the betadine dressing to the resident's right foot on January 5, 2024. However, there was no documented evidence that the betadine dressing was completed on January 6 and 7,…

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