Schuylkill Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to offer COVID-19 vaccines in accordance with facility policy to three of five residents whose vaccines were reviewed. (Residents 4, 20, and 40)Findings include: Review of the facility policy entitled, Coronavirus Disease (COVID-19)-Vaccination of Residents, last reviewed December 29, 2025, revealed that each resident was to be offered the COVID-19 vaccine according to the Centers for Disease Control (CDC) recommendations. Prior to offering the vaccine, the resident was to be provided with education regarding the benefits, risks, and potential side effects associated with the vaccine and the resident was to sign a consent to vaccinate form. Staff were to document education of the benefits and potential risks of vaccination, and whether resident received the vaccination or declined in the resident's medical record. According to the CDC recommendations entitled, COVID-19 Vaccination 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 observations and staff interview, it was determined that the facility failed to maintain sanitary conditions in the kitchen. Findings include: Observation of the kitchen on December 11, 2025, at 10:24 a.m. revealed the following: There was a black substance on the ceiling tiles above the dish machine and doorway that led from the dish room to the main kitchen. The shelves that stored clean dishes were rusted. There was an accumulation of liquid from condensation on the bars that secure the ceiling tiles in place above the food preparation area. When opened, the steamer/hot holding box in the food preparation area released a large amount of steam that billowed out into the kitchen. The flow of air and moisture was not managed to prevent an accumulation of condensation. In an interview during the observation period, the dietary director stated that ventilation system has not adequately managed condensation in the kitchen for over one month and the facility was aware. There were no remedial or temporary measures taken to reduce accumulation of moisture and condensation in the…

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

Based on review of facility documentation, the facility's meal schedule, resident and staff interview, and observation, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs for two of four nursing units. (Homestead and B-wing unit)Findings include: Review of the facility's meal schedule revealed that the scheduled time for steam table delivery for lunch on the Homestead and B-wing dining rooms was 12:00 p.m. Observation on December 11, 2025, at 12:30 p.m., on the B-wing nursing unit revealed residents seated in the dining room and the meal had not yet been served. In an interview at that time, Residents 1, 8, 9, 10, and 11 stated that meals were often served late. Continued observation revealed that the steam table delivery for lunch arrived at the unit with the meal at 12:52 p.m., and service began at 12:58 p.m. Observation on December 11, 2025, at 12:40 p.m., on the Homestead unit revealed residents seated in the dining room, the meal had not yet been served. In an interview at that time,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of facility policy, and staff interview, it was determined that the facility failed to notify the resident's physician of a change in condition for one of 12 sampled residents. (Resident 3)Findings include: Review of the facility policy entitled, Change in a Resident's Condition or Status, last reviewed January 17, 2025, revealed that the facility would promptly notify the resident's attending physician of changes in the resident's medical condition. Clinical record review revealed that Resident 3 had diagnoses that included dysphagia, anxiety, respiratory failure, and required a feeding tube. A physician's order dated November 4, 2025, directed staff to administer oxygen at two liters per minute (L/min) via nasal cannula every shift. On November 23, 2025, at 6:37 p.m., staff noted that the resident was gurgling and had an oxygen saturation of 49 percent (% ) while on supplemental oxygen and required the use of a rebreather mask at ten L/min and staff would notify the physician if his condition worsened. At 10:07 p.m., staff noted 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 clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for three of 14 sampled residents. (Residents 1, 2, 4)Clinical record review revealed that Resident 1 had diagnoses that included diabetes with hyperglycemia (high level of sugar), chronic kidney disease, and heart failure. Review of the care plan revealed that the resident had diabetes and used insulin. The intervention was for staff to administer medications per the physician's orders. A physician's order dated August 12, 2025, directed staff to administer a short acting insulin injection (Admelog) of four units with meals. Review of the manufacturer instructions for Ademlog revealed that the insulin was to be given 15 minutes before or immediately after a meal. Review of the resident details of the Medication Administration Record (MAR) for December 2025, revealed that Resident 1 was administered Ademlog at 12:15 p.m. on December 11, 2025. Observation on December 11, 2025, at 12:30 p.m. revealed that Resident 1 was seated in the dining room 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 clinical record review, staff interview, and a review of facility documentation, it was determined that the facility failed to properly use adequate supervision to prevent a fall for one of four sampled residents. (Resident 1) Findings include: Review of facility competency training records revealed that when facility staff use a mechanical lift such as a sit to stand lift, two staff members must always be present. Staff also should not ask a resident to stand for a prolonged time, such as when providing care for incontinence. Clinical record review revealed that Resident 1 had diagnoses that included chronic obstructive pulmonary disease (COPD) and a history of a stroke resulting in weakness on one side. According to the Minimum Data Set assessment, Resident 1 was dependent on staff for toileting and hygiene and was frequently incontinent of bowel and bladder. According to the comprehensive plan of care, the facility identified that the resident was at risk for falls, and that staff was to use a sit to stand mechanical lift with two persons to assist the resident 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 clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide a reasonable accommodation of needs for one of seven sampled residents. (Resident 3)Findings include: Clinical record review revealed that Resident 3 had diagnoses that included hemiparesis and unsteadiness on feet. Review of the care plan revealed that the resident required assistance from two staff and a mechanical lift for transfers, assistance from two staff for toileting (staff were to provide assistance with toileting as needed), and that the resident had been educated to call staff for assistance. On August 5, 2025, at 11:09 a.m., the resident's call bell was observed to be lit outside the room. At 11:15 a.m., the call bell remained activated. At that time, Resident 3 stated that she rang the call bell to notify staff that she required assistance to the bathroom; a staff member told her they would return with another staff member to provide assistance, but no one had returned. The resident's call bell continued to remain lit at 11:40 a.m., 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 clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for two of seven sampled residents. (Residents 1 and 2) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included diabetes mellitus. Review of the care plan revealed that staff were to obtain glucometer (device used to measure blood glucose levels) readings and report abnormalities as ordered. A physician's order dated July 11, 2025, directed staff to inject insulin lispro per sliding scale orders and notify the physician for a blood glucose reading of 400 milligrams per deciliter (mg/dL) or higher. Review of Resident 1's clinical record revealed that on July 11, 2025, staff noted a blood glucose level of 438 mg/dL at 5:01 p.m. There was no evidence that the resident's physician was notified of the blood glucose reading that was above 400 mg/dL, per the physician's order. In an interview on August 5, 2025, at 3:10 p.m., the Director of Nursing (DON) confirmed that there was no evidence that staff notified 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 facility policy review, observation, and staff interview, it was determined that the facility failed to store and serve food in a sanitary manner in the dietary department and on one of four nursing units. (Homestead) Findings include: Review of the facility policy entitled, Food Preparation and Service, dated January 17, 2025, revealed that staff were to change gloves between tasks and to wear hair restraints to cover all facial hair so that hair did not contact food. Review of the facility policy entitled, Use-By Dating Guidelines, dated January 17, 2025, revealed that staff were to label opened food items with a use-by date and cheese and lunch meat were to be used within seven days of opening. Observations during the kitchen tour on June 8, 2025, at 9:50 a.m., revealed the following: In cooler one, a large container of tea was not dated. In cooler three, there was an opened bag of sliced turkey lunch meat with an opened date of May 22, 2025. Juices from this bag were dripping onto a box of pork below it and formed a puddle on the cooler floor. There was an opened bag 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 observation, facility policy review, staff interview, and resident interview, it was determined that the facility failed to ensure that hot beverages were monitored and served at a safe temperature on the nursing units, which placed residents at risk for burn injuries. (Homestead and B Unit) In addition, the facility failed to provide adequate supervision and interventions to prevent accidents related to hot beverages for one of 35 sampled residents which resulted in a burn to the abdominal area. (Resident 105)Findings include: Review of documentation by the American Burn Association's Burn Prevention Committee entitled, Scald Injury Prevention, revealed that a scald injury occurred when a hot liquid damaged one or more layers of skin and hot beverages were a frequent source of scald burns. Older adults were the most frequent victims of scald injuries due to thin skin, reduced mobility, and reduced ability to feel heat. Hot liquid at a temperature of 155 degrees Fahrenheit (F) could result in a scald injury in one second.Review of the facility policy entitled, Safety of Hot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, review of manufacturer's instructions, and staff interview, it was determined that the facility failed to maintain a medication error rate of less than five percent (%) for two of four nursing units observed on medication administration. (Short Stay, B unit) Findings include: Observations of medication administration on June 8, 2025, from 12:50 p.m. to 1:30 p.m., and June 9, 2025, from 8:45 a.m. to 9:45 a.m., revealed 26 medication opportunities with four medication errors that resulted in a medication administration error rate of 15.38%. Clinical record review revealed that Resident 81 had diagnoses that included chronic obstructive pulmonary disease and diabetes. A review of the physician's order dated May 15, 2025, revealed that staff was to administer one puff of a tiotropium bromide (Spiriva) inhaler orally every day and was to rinse mouth after use. A review of the physician's orders dated January 21, 2025, revealed that staff was to administer 15 units of insulin glargine (LANTUS) pen-injector subcutaneously every morning and at…

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

Based on review of facility documentation, the facility's meal schedule, resident and staff interview, and observation, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs for three of four nursing units (Homestead, Short Stay, B unit) Findings include: Review of the Food Council Minutes dated May 20, 2025, revealed that Resident 62 had stated that she had to wait a long time for a meal. In a group interview on June 10, 2025, at 10:00 a.m., Resident 130, stated that the meals were frequently delivered late to the unit, it was an on-going problem, and affected her going to scheduled activities. In interviews conducted on June 8 and 9, 2025, between 12:05 p.m. and 1:45 p.m., Residents 28, 36, and 62, stated that delivery of the meal trucks and steam tables was often late. Review of the facility's meal schedule revealed that the scheduled time for steam table delivery for lunch on the Homestead unit was 12:00 p.m., for B-wing Dining Room was 12:00 p.m., and for the Short Stay unit, it was 12:30 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 policy review, clinical record review, staff interview, and a review of facility documentation, it was determined that the facility failed to keep one of three sampled residents free from neglect. (Resident 1) Findings include: Review of the facility policy entitled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last reviewed January 17, 2025, revealed that it was facility policy to protect all residents from abuse and neglect. Clinical record review revealed that Resident 1 was admitted to the facility with diagnoses that included heart and kidney disease. On February 24, 2025, staff noted that the resident was cognitively impaired, had difficulty communicating her needs, was dependent on staff for mobility, and was unable to use a toilet. According to the care plan, date February 25, 2025, the resident was at risk for developing pressure sores, and staff was to turn and reposition her every two hours. On February 26, 2025, a nurse noted that the resident was placed on a bedpan at approximately 2:30 p.m., and was not assisted off the bedpan until…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interviews, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for five of 11 sampled residents who required assistance with activities of daily living (ADLs). (Residents 1, 4, 5, 6, and 8) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus with diabetic neuropathy, and acquired absence of the right leg above the knee. Review of the resident's care plan and clinical record revealed they required assistance with bathing/showering due to their physical condition and were scheduled for showers on Monday and Thursday. There was a lack of documentation that a shower was provided on November 4, 11, and 25, 2024. In an interview on December 2, 2024, at 10:30 a.m., Resident 1 stated they had not refused a shower on those dates. Clinical record review revealed that Resident 4 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident interview, it was determined that the facility failed to provide services to enhance each resident's quality of life by offering showers as scheduled to two of eight sampled residents. (Residents 3,4) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included anxiety and insomnia. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was oriented and required staff assistance for bathing. The resident was to receive a shower twice per week. During an interview on August 25, 2024, at 10:30 a.m., the resident reported that she preferred to take a shower twice a week and was not offered the opportunity to do so. Review of documentation in the clinical record revealed that the resident was not offered a shower two of eight scheduled times in the past 30 days. Clinical record review revealed that Resident 4 had diagnoses that included hemiplegia and diabetes mellitus. The MDS assessment dated [DATE], indicated…

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

Based on clinical record review and staff interview it was determined that the facility failed to ensure that physician's orders were implemented for two of nine sampled residents. (Residents 2, 4) Findings include: Clinical record review revealed that Resident 2 had diagnoses that included hypertension and atrial fibrillation. On April 30, 2024, a physician ordered for staff to administer a medication (metoprolol) two times a day to treat the resident's high blood pressure. Staff was not to give the medication if the resident had a systolic blood pressure less than 100 mm/Hg (millimeters of mercury). A review of the May 2024 medication administration record (MAR) revealed that staff administered the medication when the resident's systolic blood pressure was under the established parameter 15 times. Clinical record review revealed that Resident 4 had diagnoses that included hypertension and atrial fibrillation. On January 6, 2024, the physician ordered that staff administer a medication (carvedilol) once a day to treat the resident's high blood pressure and to withhold 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 observation and staff interview, it was determined that the facility failed to store food under sanitary conditions in the kitchen. Findings include: In an interview on May 7, 2024, at 9:30 a.m., the Director of Dietary Services stated that refrigerated foods were to be labeled and dated when opened and used within three days. Observation of the kitchen during a tour on May 7, 2024, at 9:32 a.m., revealed the following in the walk-in refrigerator: a container of opened pumpkin puree dated May 2, 2024, opened raspberry glaze dated April 25, 2024, pureed peaches dated May 3, 2024, a dish of cottage cheese that was undated, a dish of salad dated May 2, 2024, and a container of spaghetti with sauce without a date. In reach-in refrigerator 1, there was a dish of chopped lettuce that was browning dated May 2, 2024, and in reach-in refrigerator 3, there was opened ham luncheon meat dated April 29, 2024, opened turkey luncheon meat dated April 29, 2024, and a container of chicken dated May 2, 2024. In the walk-in freezer, there was a large accumulation of ice buildup on food items…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility documentation, results of a test tray, and staff interview, it was determined that the facility failed to follow the pre-approved menus on one of four nursing units. (C Unit) Findings include: Review of monthly Resident Council and Food Committee meeting minutes from December 2023, through April 2024, revealed a pattern of complaints about portion size of food at mealtimes. On May 8, 2024, at 10:30 a.m., residents in a confidential group meeting stated that portion sizes were often too small. Review of the facility menus revealed the lunch meal on May 8, 2024, was to include three ounces of glazed pork medallions and four ounces of California blend vegetables. Results of a test tray audit conducted on May 8, 2024, from 12:05 p.m. through 12:20 p.m., revealed staff served two ounces of glazed pork and three ounces of California blend vegetables. In an interview on May 8, 2024, the Dietary Manager confirmed that the incorrect portion size was given for the entree and vegetables for the lunch cart delivered to C Unit. 28 Pa. Code 211.6(a) Dietary services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for two residents (Residents 42, 74) on two of four nursing units. (Homestead and C Unit) Findings include: Clinical record review revealed that Resident 42 had diagnoses that included Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had cognitive impairment, and required supervision with eating. Review of Resident 42's current care plan revealed that the resident was on a restorative nursing program for dining and staff was to provide assistance with meals. Observation on May 7, 2024, from 1:37 p.m. through 1:50 p.m., revealed Resident 42 in the dining room on the Homestead nursing unit eating spaghetti with meat sauce with her fingers. At no time did staff redirect or offer assistance to Resident 42. Clinical record review revealed that Resident 74 had diagnoses that included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for two of 34 sampled residents. (Resident 141, 168) Findings include: Clinical record review revealed that Resident 141 had diagnoses that included difficulty communicating due to a cognitive issue, hearing loss, and dementia. The Minimum Data Set (MDS) assessment dated [DATE], identified that Resident 141 was cognitively impaired and used hearing aids. The Care Area Assessment (CAA) summary indicated that communication was to be addressed in the care plan. There was no evidence that interventions to address Resident 141's communication problems were included in the current care plan. Clinical record review revealed that Resident 168 had diagnoses that included dementia and chronic kidney disease. The MDS assessment dated [DATE], indicated that Resident 168 was occasionally incontinent of urine and the CAA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident interview, and results of a test tray audit, it was determined that the facility failed to provide food that was palatable and at appetizing temperatures on one of four nursing units. (C Unit) Findings include: On May 7, 2024, at 1:10 and 1:15 p.m., Residents 66 and 74 stated their lunch was cold to taste. Review of monthly Resident Council and Food Committee meeting minutes from December 2023 through April 2024, revealed a pattern of complaints about food not being served at correct temperatures. In a confidential group interview on May 8, 2024, at 10:30 a.m., residents also stated that food was often not the right temperature and the pork was too tough. Results of a test tray audit conducted on May 8, 2024, at 12:10 p.m., revealed glazed pork was served at a temperature of 120.7 degrees Fahrenheit (F), scalloped potatoes at a temperature of 111 degrees F, and California blend vegetables at a temperature of 116 degrees F. The food was cool to taste and the pork tough and difficult to chew. On May 8, 2024, from 12:10 p.m. through 12:35 p.m., Residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and staff interview, it was determined that the facility failed to ensure that adaptive equipment was provided to two of four sampled residents who used adaptive equipment for meals. (Residents 29, 76) Findings include: Clinical record review revealed that Resident 29 had diagnoses that included Parkinson's disease, dementia, arthritis, and a lack of coordination. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had cognitive impairment and required assistance from staff for all meals. A review of the care plan revealed that the resident had a nutrition problem related to a history of weight loss and that staff was to provide adaptive equipment including Kennedy cups (spill proof drinking cups that included a lid and a straw) for all meals. On May 3, 2023, the dietitian documented that the resident continued to benefit from the use of adaptive equipment at meals. On May 8, 2024, at 1:10 p.m., Resident 29 was observed in bed immediately…

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