Rochester Residence And Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, facility documents and staff interviews, it was determined that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for three of four residents (Resident R3, R9, and R55).Findings include: Review of facility policy Pressure Injury Prevention Guidelines dated 12/11/25, indicated to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of the facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/8/26, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for five of six residents (Resident R2, R29, R34, R60 and R65). Findings include: Review of facility policy Oxygen Concentrator dated 12/11/25, indicated this policy is to establish responsibilities for the care and use of oxygen concentrators. Oxygen is administered under orders of the attending physician. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Review of the facility policy Oxygen Administration dated 12/11/25, indicated oxygen is administered to residents who need it, consistent with professional standards of practice. Infection control measures include but not inclusive to change the oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. If applicable, change the nebulizer tubing and delivery device every 72 hours or per facility policy and…

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

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly secure a treatment cart while not in use for one of two treatment carts (4th Floor Treatment Cart), failed to properly secure lab work supplies while not in use for one of two nursing units (4th Floor), and failed to properly store medication in two of three medication carts (Grandview Medication Cart and Riverview Medication Cart). Findings include: Review of facility policy Medication Storage dated 12/11/25, indicated all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Only authorized personnel will have access to the keys to locked compartments. During an observation on 2/9/26, at 12:15 p.m. the 4th Floor Treatment Cart was observed at the nurses station unlocked and unattended. During an observation on 2/9/26, at 12:19 p.m. a plastic portable caddy was observed at the 4th Floor nurses station unsecured and unattended. The caddy…

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 job descriptions, facility and clinical records, and staff interviews, it was determined that the former Nursing Home Administrator (NHA) Employee E31 and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper supervision was provided for residents at high risk for elopement as required, resulting in a resident elopement creating an immediate jeopardy situation.Findings include: The job description for the Nursing Home Administrator (NHA) dated 2/9/26, indicated the NHA leads, guides, and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards, and established facility policies and procedures to provide appropriate care and services to residents. Ensures delivery of compassionate quality care and services across an interdisciplinary team. Performs rounds to observe residents and ensure overall needs are met. Ensures resident incidents and concerns that rise to a reportable event including but not inclusive to such alleged abuse, neglect, mistreatment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that hospice documentation was maintained for three of three residents reviewed for hospice services (Resident R9, R23, and R65). Findings include: Review of facility policy Coordination of Hospice Services 12/11/25, indicated when a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of Resident R9's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/17/26, indicated diagnoses diabetes mellitus, hypertension and anxiety disorder. Review of Resident R9's physician orders dated 1/13/26 revealed an order for hospice services. Resident R9 clinical record lacked evidence that the hospice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policies, clinical record review, facility documents, observation, and staff interview, it was determined that the facility failed to ensure proper hand hygiene on six of six nursing units (Lilac Lane, Rosewood, Vineyard, Riverview, Hilltop, and Grandview), failed to prevent cross contamination during a dressing change for one of two residents (Resident R9), failed to properly monitor a resident's refrigerator temperature for one of two residents (Resident R44), and failed to monitor the results of blood cultures (a blood test used to determine if infection is present in blood stream) for one of three residents (Resident R2). Finding include: Review of facility policy Hand Hygiene dated 12/11/25, indicated that all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method of cleaning hands in most clinical situations. All staff will perform proper hand…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to timely offer and provide the COVID-19 vaccination for three of five residents (Residents R16, R71, and R72).Findings include: Review of facility policy COVID-19 - Vaccination Policy dated 12/11/25, indicated all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. Prior to receiving vaccination, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. Provision of such education shall be documented in the resident's medical record. If vaccines are refused, the refusal shall be documented in the resident's medical record. Review of the clinical record revealed Resident R16 was admitted to the facility on [DATE].Review of Resident R16's Minimum Data Set (MDS - a periodic assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for two of five residents (Residents R23 and R55).Findings include: Review of facility policy Call Lights: Accessibility and Timely Response dated 12/11/25, indicated staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Review of the clinical record revealed Resident R23 was admitted to the facility on [DATE]. Review of Resident R23's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/8/26, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and depression. During an observation on 2/9/26, at 9:28 a.m. Resident R23 was observed lying in their bed. Resident R23's call bell was wrapped around the headboard, out of the resident's reach. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that each resident's drug regimen was free from unnecessary psychotropic drugs used without adequate indications for use for one of three residents (Resident R77).Findings include: Review of the admission record indicated Resident R77 was admitted to the facility on [DATE] Review of Resident R77's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/5/25, indicated the diagnoses of hypertension (high blood pressure), depression, and hyperlipidemia. Review of Section N: Medications revealed Resident R77 received antipsychotic medications in the seven days prior to the assessment and that an indication is noted Review of Resident R77's physician order dated 8/5/25, indicated risperidone 0.5 milligram tablet two times a day for agitation. Review of Resident R77's psychiatric progress note dated 8/21/25, indicated diagnosis dementia with other behavioral…

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, newly hired personnel records and staff interviews it was determined that the facility failed to properly screen an employment by completing a state certification/license check prior to hire for two out of five personnel records (Nurse Aide (NA) Employee E19 and Licensed Practical Nurse (LPN) Employee E20). Findings include: Review of the facilities Abuse, Neglect and Exploitation policy dated 12/11/25, indicated the facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Screening: potential employees will be screened for a history of abuse, neglect, exploitation, and misappropriation of resident property. Background, reference, and credentials' checks will be conducted on potential employees. Review of the facilities License Verification policy dated 12/11/25, indicated all personnel that requires a license or certification shall be verified through the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for one of five residents (Residents R26).Findings include: Review of facility policy Conducting an Accurate Resident assessment dated [DATE], indicated the purpose is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated the following instructions:N0415G1, Diuretic: check if a diuretic medication was taken by the resident at any time during the 7-day look-back period (or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review facility policies, observations, clinical records, and staff interviews, it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of an indwelling urinary catheter (closed sterile system inserted into the bladder to allow for urine drainage) as required for two of three residents (Resident R34 and R88).Findings include: Review of facility policy Resident Rights last reviewed 12/11/25, indicated the resident has a right to a dignified existence. The resident has a right to personal privacy. Review of the clinical record indicated Resident R34 was admitted to the facility on [DATE]. Review of Resident R34's MDS dated [DATE], indicated diagnoses of hyperlipidemia (high fat in the blood), anxiety and urinary retention (bladder doesn't empty completely). Review of Resident R34's physician orders dated 2/1/26, indicated catheter/foley size 18 french with 10 cubic centimeter (cc) balloon. During an observation completed on 2/9/26, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a midline catheter (a thin flexible tube inserted into a vein in the upper arm with the tip positioned just below the armpit) for one of two residents (Resident R5).Findings include: Review of Resident R5's admission record indicated the resident was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - periodic assessment of care needs) dated 11/11/25, indicated diagnoses of anemia (low iron in the blood), heart failure (heart doesn't pump the way it should) and hypertension (high blood pressure). Review of physician orders dated 2/3/26, at 6:00 pm indicated Sodium Chloride Solution 0.9 % (a supplemental fluid used for hydration) at 100 milliliters (ml)/ hour (hr) intravenously (IV-administering fluids or medications directly through a vein) for 24 hours. Review of physician orders dated 2/3/26, at 6:45 p.m. indicated Midline…

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

Based on review of personnel records and staff interview, it was determined that the facility failed to complete annual performance evaluation at least once every 12 months for one of three nurse aide (NA) personnel records (NA Employee E28).Findings include: Review of NA Employee E28's personnel record indicated a hire date of 10/18/23. Review of NA Employee E28's personnel records revealed that the latest performance evaluation was conducted on 1/8/24. During an interview on 2/12/25, at 12:11 a.m. the Human Resources Employee E9 confirmed that there was not a performance evaluation conducted in the year 2025 for NA Employee E28, and the facility failed to complete annual performance evaluation at least every 12 months for NA Employee E28 as required. 28 Pa Code: 201.14 (b) Responsibility of licensee28 Pa Code: 201.18 (b)(1)(3) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of three residents reviewed (Resident R55).Findings include: Review of facility policy Dementia Care dated 12/11/25, indicated the facility will provide the appropriate treatment and services to every resident who displays signs of or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. The care plan goals will be achievable and the facility will provide resources necessary for the resident to be successful in meeting their goals. The care plan interventions will be related to each resident's individual symptomology and rate of dementia (or related disease) progression with end result being noted improvement or maintained of the expectation stable rate of decline associated with dementia and dementia-like illnesses. Care and services…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Effective Communication for two of five staff members (Registered Nurse (RN) Employee E29, and E30).Findings include: Review of facility policy Training Requirements dated 12/11/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Effective Communication. Review of RN Employee E29's personnel file indicated 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 facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Resident Rights for two of five staff members (Registered Nurse (RN) Employee E29, and E30).Findings include: Review of facility policy Training Requirements dated 12/11/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Resident Rights. Review of RN Employee E29's personnel file indicated a hire date 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 facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for two of five staff members (Registered Nurse (RN) Employee E29, and E30).Findings include: Review of facility policy Training Requirements dated 12/11/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Abuse, Neglect, and Exploitation Prevention. Review of RN Employee E29's…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program for two of five staff members (Registered Nurse (RN) Employee E29, and E30).Findings include: Review of facility policy Training Requirements dated 12/11/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum QAPI program. Review of RN Employee…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Infection Control for two of five staff members (Registered Nurse (RN) Employee E29, and E30).Findings include: Review of facility policy Training Requirements dated 12/11/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Infection Prevention, and Control Program. Review of RN Employee E29's personnel file…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for two of five staff members (Registered Nurse (RN) Employee E29, and E30).Findings include: Review of facility policy Training Requirements dated 12/11/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Compliance and Ethics Program. Review of RN Employee E29's personnel file 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 review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Behavioral Health for two of five staff members (Registered Nurse (RN) Employee E29, and E30).Findings include: Review of facility policy Training Requirements dated 12/11/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Behavioral Health. Review of RN Employee E29's personnel file indicated a hire date 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 facility policy, observation and staff interview it was determined that the facility failed to properly contain and dispose of garbage in outside dumpsters to prevent the potential for rodent and insect infestation.Findings include:Review of facility policy Disposal of Garbage and Refuse, dated 12/11/25, indicates that the facility shall dispose of kitchen garbage and refuse. There shall be sufficient numbers of receptacles to hold refuse where refuse is discarded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. Garbage should not accumulate or be left outside the dumpster.During an observation on 1/29/26, at 5:38 p.m. the outdoor trash compactor had two shopping carts, an oversized chair, many empty cardboard boxes, and an uncountable amount of filled garbage bags sitting around the dumpster.During an interview on 1/29/26, at 6:00 p.m. the Nursing Home Administrator confirmed that that there were trash and debris collecting in the disposal area, and that the facility failed to properly contain and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical records, observations and staff interviews, it was determined that the facility failed to determine whether it was safe to self-administer medications for one of four residents (Resident R1).Findings include:Review of the facility policy Resident Self-Administration of Medications dated 12/11/25, indicated the facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of resident R1's Minimum Data Set (MDS-a periodic assessment of care needs) dated 11/3/25, indicated the diagnoses of high blood pressure, anemia (too little iron in the body causing fatigue), and dementia (a group of symptoms that affect memory, thinking and interferes with daily life). Resident R1's MDS assessment section C0200…

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

Based on review of facility policy, observations, and staff interviews it was determined that the facility failed to maintain the confidentiality of residents' medical information on three of four medication carts (Vineyard, Rosewood, and Rosewood 2). Findings include:Review of facility policy HIPAA Security Measures dated 12/11/25, indicated it's the facilities policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and records that are in electronic format.During an observation on 1/29/26, at 10:45 a.m. the Vineyard Medication Cart and the Rosewood Medication Cart were observed sitting in the hallway, beside each other, and was left unattended with the computer screen open with identifiable information and any passerby could see resident personal and confidential information. During an interview on 1/29/26, at 10:47 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the Vineyard Medication Cart computer screen was left unattended with the computer screen open…

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, the facility failed to ensure the outside environment was free of potential accidental hazards, failed to evaluate the snow hazard, and failed to implement a plan for snow removal for two of two parking lot areas, walkways and surrounding grounds three days after a snowstorm (Front Parking and Rear Parking Area).Findings include:During an observation on 1/28/26, at 3:00 p.m. when the State Agency (SA) arrived at the facility, the front parking lot used to maintain a flow of vehicles for visitors, transport, and ambulances was impassable. Only one entrance way was plowed, which would cause emergency vehicles to have a difficult time turning around and exit the parking lot in case of an emergency. The exit to leave the parking lot was not plowed and snow was impeding the ability to leave quickly. Additionally, sidewalks leading to the building were not shoveled. The second parking area was covered with snow and not plowed, and vehicles were stuck in lot. During a review of a family member's concern dated 1/28/26, at 11:59…

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

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly secure a medication cart while not in use for three of four medication carts (Vineyard, Rosewood, and Rosewood 2).Findings include:Review of facility policy Medication Storage dated 12/11/25, indicated all drugs and biologicals will be stored in locked compartments (medication carts, cabinets, drawers, refrigerators, and medication rooms). During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication cart.During an observation on 1/29/26, at 10:45 a.m. the Vineyard Medication Cart and the Rosewood Medication Cart were observed sitting in the hallway, beside each other, with the cart unlocked and unattended. During an interview on 1/29/26, at 10:47 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the Vineyard Medication Cart was unlocked, unattended, and that the facility failed to properly secure a medication cart while not in use.During an interview on 1/29/26, at…

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

Based on review of job descriptions, clinical records, observations, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to ensure comfortable air temperature levels (between 71-81 degrees Fahrenheit) were provided in the facility, and failed to monitor and assess all residents for hypothermia (a life-threatening medical emergency when the body loses heat faster than it can produce it), which created an Immediate Jeopardy situation, for 82 of 82 residents.Findings include:The job description for the Nursing Home Administrator dated 12/19/24, indicated the NHA leads, guides, and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards, and established facility policies and procedures to provide appropriate care and services to residents. Plans, develop, organize, implement, evaluate, and direct the overall operation of the facility. Performs rounds to observe residents and ensure overall needs are met. Participates in safety and emergency drills. Fulfills…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, review of facility documents, and resident records, resident council group interview, review of resident representative concern, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for two of two residents (Resident R18 and R51), failed to assist a resident to eat in a timely manner and failed to ensure that food was provided in a manner which maintained resident dignity for one of four residents (Resident R67), and failed to provide a dignified dining experience for all residents for three out of six months (July, August, and September 2025). Findings include: Review of facility policy Catheter Care dated 1/7/25, indicated privacy bags will be available and catheter drainage bags will be covered at all times while in use. Review of facility policy “Activities of Daily Living (ADLs)” dated 1/7/25, indicated the facility will ensure a resident's abilities in ADL's do not deteriorate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to accommodate the proper linen needs for two of two units (third and fourth floors) and provide a clean, safe, comfortable and homelike environment on one of two nursing units (Third Floor).Findings include: A review of facility policy Safe and Homelike Environment dated 1/7/25, indicated in accordance with residents ' rights, the facility will provide a safe, clean, comfortable and homelike environment. This includes ensuring that the residents can receive care and services safely. The facility will provide and maintain bed and bath linens that are clean and in good condition. During a tour of the facility on 9/15/25, at 9:20 a.m. the following was observed:-The clean linen rack on the fourth floor outside room [ROOM NUMBER], failed to have linen that was in good condition. Observation revealed that eight pieces of towel were ripped in pieces to create washcloths. Also noted were ripped bath…

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 policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility.Findings include: A review of facility policy Sanitation Inspection dated 1/7/25, indicated as part of the sanitation program, facility will conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations. All food service areas shall be kept clean, sanitary, free from litter, rubbish, and protected from rodents, roaches, and flies and other insects. During an observation on 9/15/25, at 10:05 a.m., of the walk-in cooler in the main kitchen, conducted with Certified Dietary Manager (CDM) Employee E22, revealed that the cold air condenser unit had a build-up of dust, grime, and dark colored debris around the fan covers and ceiling immediately forward of the fans. CDM Employee E22 confirmed observation by surveyor when viewed. During an interview on 9/15/25, at 10:10…

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

Based on review of facility policy, observation and staff interview it was determined that the facility failed to properly contain and dispose of garbage in outside dumpsters to prevent the potential for rodent and insect infestation.Findings include: Review of facility policy Disposal of Garbage and Refuse, dated 1/7/25 indicates that the facility shall dispose of kitchen garbage and refuse. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. Garbage should not accumulate or be left outside the dumpster. During an observation and interview of the facility's outdoor trash compactor on 9/15/25, at 10:00 a.m. with Certified Dietary Manager (CDM) Employee E22 confirmed that there were trash and debris collecting in the disposal area, and that the facility failed to properly contain and dispose of garbage in outside dumpster area to prevent potential rodent and insect infestation. 28 Pa. Code 201.18(b)(3) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, facility documents, observation, and staff interview, it was determined that the facility failed to ensure proper hand hygiene, failed to prevent cross contamination during a dressing change for one of three residents (Resident R74), and failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections, identify floor mapping for three of five months (July, August, and September 2025) and failed to implement Covid outbreak response timely for one of three residents (Resident R72). Finding include: Review of facility policy Hand Hygiene dated 1/7/25, indicated that all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method of cleaning hands in most clinical situations. All staff will perform proper hand hygiene procedures to prevent the spread…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations and staff interview, it was determined that the facility failed to determine it was safe to self-administer medications for three of eleven residents (Resident R4, R26 and R61).Findings include: Review of the facility policy Resident Self -Administration of Medications dated 1/7/25, indicated residents will be permitted to self-administer medication after evaluation by their interdisciplinary team and approval from their medical provider. If the interdisciplinary team indicates that a resident is able to safely self-administer medications the provider will write an order authorizing the resident to self-administer the medication. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of R4's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/5/25, indicated the diagnoses of chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), anxiety (intense,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and documentation, staff and resident interviews it was determined that the facility failed to protect residents from neglect and verbal abuse for three of three residents (Resident R13, R26, and R32). Findings include: Review of facility policy Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 1/7/25, indicated: Neglect is the failure of the home, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully include disparaging and derogatory terms to residents. Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2024, indicated that a Brief Interview for Mental Status (“BIMS”) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medications for four of five residents (Residents R1, R6, R28, and R33).Findings include: Review of facility policy Psychotropic Medication Use dated 1/7/25, indicated residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-psychotics, anti-depressants, anti-anxiety medications, and hypnotics/sedatives. Review of facility policy Medication Regimen Reviews (MRR) dated 1/7/25, indicated a licensed pharmacist reviews the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weights for four of four residents (Residents R7, R10, R29, and R56) reviewed.Findings included: Review of facility policy Weight Monitoring, dated 1/7/25, indicated the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. A weight monitoring schedule will be developed upon admission for all residents. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/18/25, indicated diagnoses of high blood pressure, muscle weakness, and need for assistance with personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for three of four residents (Residents R4, R10, and R17).Findings include: Review of facility policy Nebulizer Therapy dated 1/7/25, indicated care of equipment includes clean after each use, disassemble parts after every treatment, rinse the nebulizer (a machine used to deliver aerosolized medications) cup and mouthpiece with sterile or distilled water, and once completely dry, store the nebulizer cup and the mouthpiece in a Ziplock bag. Change nebulizer tubing every seventy-two hours or per facility policy. Review of the clinical record indicated Resident R4 admitted to the facility on [DATE]. Review of R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/5/25, indicated the diagnoses of chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), anxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis (a machine that filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for three of three residents (Residents R10, R34, and R72), and failed to develop a comprehensive person-centered care plan to address resident needs for one of three residents (Resident R72).Findings include: Review of facility policy Hemodialysis dated 1/7/25, indicated the facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. The licensed nurse will communicate to the dialysis facility via telephonic communication 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 policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being on four of five days (9/15/25, 9/16/25, 9/17/25, and 9/18/25).Findings include: Review of facility policy Nursing Services Sufficient Staff dated 1/7/25, indicated the facility will provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. During an interview on 9/15/25, at 12:32 p.m. Nurse Aide (NA) Employee E1 stated, We've been having a problem for a while now. Weeks, at least a month. We don't have enough towels, wash cloths, fitted sheets. We 100% have not been able to give baths or showers because we don't have enough staff or supplies. We have to pick and choose who gets…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to provide documentation of medication regimen reviews (MRR) were completed at least monthly for four of five sampled resident records (Resident R1, R3, R28, and R33). Findings include: The facility Medication Regimen Review policy last reviewed 1/7/25, indicated the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. Mediation Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. Written communication from the pharmacist shall become a permanent part of the resident's medial record. The pharmacist shall communicate any recommendations and identified irregularities via written communication within 10 working days of the…

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

Based on review of facility documents, resident council group interviews, and staff interviews, it was determined the facility failed to consistently provide snacks as desired by residents for of one of two Nursing Units (Fourth Floor). Findings include: Review of Dietary Tray line Start Times indicated the following meal schedule:Breakfast 7:15 a.m.Lunch 11:30 a.m.Dinner 4:45 p.m. Review of the above schedule revealed a span of 14.5 hours from the start of dinner tray line to the start of breakfast tray line. Resident Council Meeting Minutes dated 8/13/25, stated that Residents on the 4th floor ask nurses/aides for a snack and that it is served on occasion. Review of Resident Council Meeting Minutes dated 8/20/25, stated New business 4th floor snack cart- evening snacks are not being passed out. Review of Resident Council Meeting Minutes dated 9/10/25, stated New business- some residents are receiving snacks on their evening meal tray, others not receiving depending on staff working. During a group interview on 9/16/25, at 1:30 p.m. the following statements were made regarding…

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 infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for three of five months (July, August, and September 2025).Findings include: Review of facility policy Antibiotic Stewardship Program dated 1/7/25, indicated Antibiotic Stewardship Program (ASP) is implemented as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Review of the facility's Infection Control surveillance for April 2025 - September 2025 failed to include documentation to indicate that antibiotic monitoring was completed for July, August, and September 2025. Interview on 9/18/25, at 12:09 p.m. the Director of Nursing confirmed that the facility failed to implement an antibiotic stewardship program for three of five months (July, August, and September 2025). 28 Pa. Code: 211.10(c)(d) Resident care policies.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the Influenza vaccine for three of five residents (Resident R1, R4, and R72) and related to the pneumonia vaccine for four five residents (Resident R1, R4, R29, and R72). Findings include: Review of facility policy Influenza, Prevention and Control of Seasonal dated 1/7/25, indicates this facility follows current guidelines and recommendations for the prevention and control of seasonal influenza. All residents and staff are offered the vaccine prior to the onset of the influenza season. Review of the facility policy Pneumococcal Vaccine last reviewed 1/7/25, indicates all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated will be offered the vaccine series within…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R10).Findings include: Review of facility policy Call Lights: Accessibility and Timely Response dated 1/7/25, indicated staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/6/25, indicated diagnoses of End-Stage Renal Disease (ESRD - an inability of the kidneys to filter the blood), aphasia (language disorder that affects communication), and hemiplegia (paralysis on one side of the body). During an observation on 9/16/25, at 9:18 a.m. Resident R10 was observed laying in their bed. Resident…

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

Based on review of facility policy, Resident Group interviews, Resident Council meeting minutes, and staff interview it was determined the facility failed to consider the views of a resident and/or family and act promptly on grievances and recommendations concerning issues of resident care and life in the facility for three of four months (July, August, September 2025).Findings include: Review of facility policy titled Resident and Family Grievances dated 1/7/25, indicated that grievances may be voiced as a verbal complaint during resident or family council meetings. The facility will make prompt efforts to resolve grievances. Review of Dietary Tray line Start Times indicated the following meal schedule:Breakfast 7:15 a.m.Lunch 11:30 a.m.Dinner 4:45 p.m. Review of the above schedule revealed a span of 14.5 hours from the start of dinner tray line to the start of breakfast tray line. Review of Resident Council Meeting Minutes dated 7/2/25, stated Foods are served on foam plates. Would like to have soup in a different container. Not Styrofoam. Resident Council Meeting Minutes dated…

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 post complete contact information for Adult Protective Services as required, on two of two nursing units (Third Floor, and Fourth Floor Nursing Units). Findings include: During observations completed on 9/18/25, of the Third Floor, and Fourth Floor Nursing Units failed to reveal contact information including, name, mailing address, email address, and phone number for Adult Protective Services posted in a form and manner accessible and understandable to residents or resident representatives. During interview, on 9/18/25, at 1:24 p.m., the Nursing Home Administrator confirmed that the facility failed to post contact information for Adult Protective Services as required, on two of two nursing units. 28 Pa. Code: 201.14(a)Responsibility of licensee.28 Pa. Code: 201.18(e) Management.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident records, admission documentation and staff interview, it was determined that the facility failed to maintain admission documentation for one of two residents (Resident R48).Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024 indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed that Resident R48 was admitted to the facility on [DATE]. Review of Resident R48's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 6/27/25, indicated diagnoses that include abdominal pain, anemia (too little iron in the body causing fatigue), and generalized edema (an accumulation of fluid in the body's tissues). Section C0500 includes a BIMS of 15, which indicated resident is cognitively intact.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of three residents sampled with facility-initiated transfers (Resident R5), and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of three resident hospital transfers (Resident R5).Findings include: Review of facility policy Transfer and Discharge (including AMA) dated 1/7/25, indicated for a transfer to another provider, for any reason, the following information must be provided to the receiving provider:Contact information of the practitioner who was responsible for care of the resident;Resident representative information, including contact information;Advance directive information;All other information necessary to meet the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident communication care needs for one of five residents (Resident R10).Findings include: Review of facility policy Comprehensive Care Plans dated 1/7/25, indicated the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Review of facility policy Use of Assistive Devices dated 1/7/25, indicated the facility will provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity. Assistive devices are tools, products, types 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 clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one of two residents (Resident R10).Findings include: Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/6/25, indicated diagnoses of End-Stage Renal Disease (ESRD - an inability of the kidneys to filter the blood), aphasia (language disorder that affects communication), and hemiplegia (paralysis on one side of the body). Review of a physician order dated 7/28/25, indicated to have right resting hand splint with digit separators on right hand during night. Apply with evening care and remove with morning care. Check skin upon application and removal. Review of a physician order dated 8/1/25, indicated to wear rolled washcloth in right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate monitoring of elopement (leaving an area without permission) prevention devices for one out of three residents (Resident R5).Findings include: Review of facility policy Elopements and Wandering Residents dated 1/7/25, indicated the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation and staff interviews, it was determined the facility failed to dispose of or reconcile discontinued medication in a timely manner for one of two medication rooms reviewed (Fourth Floor Medication Room). Findings: Review of facility Destruction of Unused Drugs policy dated [DATE], indicated that all unused, contaminated, or expired prescription drugs shall be disposed of. Unused, unwanted and non-returnable medications should be removed from their storage area. A non-controlled medication destruction record must be maintained for all non-controlled drugs. During a medication room review on [DATE], at 9:53 a.m. three bags with medications was observed sitting on a table, unsecured and unaccounted for. The medications observed were: - Sertraline (used to treat depression) 23 pills- Famotidine (used to treat acid reflux) 23 pills- Lisinopril (used to treat high blood pressure) 24 pills- Metformin (used to treat high blood sugar) 47 pills- Keppra (used to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in one of two medications rooms (Fourth Floor Medication Room), and one of three medication carts (Lilac Lane Medication Cart).Findings include: Review of facility policy Medication Storage dated [DATE], indicated the facility will ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. During an observation on [DATE], at 10:10 a.m. of the Fourth Floor Medication Room revealed the following: - Lantus (a long-acting Insulin used to treat high blood sugars) – opened with no expiration date. - Two Debridement (used for wounds) Kits expired [DATE]. - One Urethral Cath Kit expired [DATE]. - Two Urethral Cath Kit expired [DATE]. - Four Yanker Suctioning devices…

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 the facility failed to obtain laboratory services as ordered for one of two residents (Resident R33).Findings Include: A review of the facility Laboratory Services and Reporting reviewed 1/7/25, indicated the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The facility must provide or obtain laboratory to meet the needs of its residents. The facility is responsible for the timeliness of the service. A review of the facility Provision of Physician Ordered Services last reviewed 1/7/25, indicated the facility will provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. The facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician orders. Review of the clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, review of clinical record, observations, and staff interviews, it was determined that the facility failed to provide food in a form to meet an individuals' needs in one of three residents ordered a regular diet (Resident R28), and failed to provide drinks in a form to meet individuals' needs in one of three residents (Resident R76).Review of the facility policy Therapeutic Diets dated 1/7/25, indicated that the facility provides all resident with food in the appropriate form and the appropriate nutritive content as prescribed by a physician to support the resident's treatment, plan of care with his or her goals and preferences. Mechanically altered diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids. Review of the clinical record revealed that Resident R28 was admitted to the facility on [DATE]. Review of Resident R28's MDS (Minimum Data Set, periodic 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, family interview, and staff interviews, it was determined that the facility failed to ensure a clean, sanitary, and functional environment on the nursing unit for one of two floors (Fourth Floor).Findings include: Review of the facility policy Preventative Maintenance Program last reviewed 1/7/25, indicated a program shall be developed and implemented to ensure the provision of a safe, functional, sanitary environment for residents, staff, and the public. During an observation completed on 9/15/25, at 10:50 a.m. room [ROOM NUMBER]'s bathroom revealed that no water was coming out of the hot water spigot and was not in working order. During an interview on 9/15/25, at 11:09 a.m. Registered Nurse (RN) Employee E2 confirmed that hot water is needed to give bed bathes, and the hot water was not in working order. During an interview on 9/15/25, at 1:32 p.m. Nurse Assistant (NA) Employee E28 stated, I have to go to another resident's room or to the shower room to get water for the residents in…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Effective Communication for two of five staff members (Registered Nurse (RN) Employee E19, and Nurse Aide (NA) Employee E20).Findings include: Review of facility policy Training Requirements dated 1/7/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Effective Communication. Review of RN Employee E19's…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Resident Rights for two of five staff members (Registered Nurse (RN) Employee E19, and Nurse Aide (NA) Employee E20).Findings include: Review of facility policy Training Requirements dated 1/7/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Resident Rights. Review of RN Employee E19's personnel file…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for two of five staff members (Registered Nurse (RN) Employee E19, and Nurse Aide (NA) Employee E20).Findings include: Review of facility policy Training Requirements dated 1/7/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Abuse, Neglect, and Exploitation Prevention.…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program for two of five staff members (Registered Nurse (RN) Employee E19, and Nurse Aide (NA) Employee E20).Findings include: Review of facility policy Training Requirements dated 1/7/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum QAPI program.…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Infection Control for two of five staff members (Registered Nurse (RN) Employee E19, and Nurse Aide (NA) Employee E20).Findings include: Review of facility policy Training Requirements dated 1/7/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Infection Prevention, and Control Program. Review of RN Employee…

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

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for two of five staff members (Registered Nurse (RN) Employee E19, and Nurse Aide (NA) Employee E20).Findings include: Review of facility policy Training Requirements dated 1/7/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Compliance and Ethics Program. Review of RN Employee E19's…

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

Based on review of facility policy, personnel records, and staff interview it was determined that the facility failed to ensure that one of four sampled Nurse Aides (NA) received a minimum of 12 hours of in-service education per year (NA Employee E20).Findings include: Review of facility policy Required Training, Certification and Continuing Education of Nurse Aides dated 1/7/25 indicated that the facility will provide at least 12 hours of in-service training annually, based on the employment date, not calendar year. Review of facility nurse aide training records revealed that NA Employee E20 did not receive 12 hours of in-service training in the last year. The facility was unable to provide documented evidence that NA Employee E20 had received a minimum of 12 hours of in-service training yearly. During an interview on 9/18/25, at 8:36 a.m. Human Resources Employee E21 confirmed that the facility did not have evidence that NA Employee E20 received the required 12 hours of yearly in-service training 28 Pa. Code: 201.14(a) Responsibility of Licensee.28 Pa. Code: 201.20(c) 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 and documents, and staff interview, it was determined that the facility failed to provide training on Behavioral Health for two of five staff members (Registered Nurse (RN) Employee E19, and Nurse Aide (NA) Employee E20).Findings include: Review of facility policy Training Requirements dated 1/7/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Behavioral Health. Review of RN Employee E19's personnel file…

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

Based on a review of facility menu, and resident and staff interviews, it was determined that the facility failed to follow the facility menu, and serve palatable food for the lunch meal served on 8/7/25, breakfast meal served on 8/9/25, and dinner meal served on 8/9/25.Findings include: Review of facility menu indicated that on 8/7/25, at lunch the following was to be served:Tossed salad with dressingChicken fettuccini alfredo Review of facility menu indicated that on 8/9/25, at dinner the following was to be served:Beef chili with beans Review of a Resident Representative concern dated 8/7/25, stated He was served a scoop of buttered noodles and a salad with no dressing for lunch. During an interview on 8/12/25, at 12:34 p.m. Nurse Aide (NA) Employee E1 stated This weekend the kitchen served scrambled eggs and poured chicken soup over top of them. When asked why this was done NA Employee E1 stated To keep them moist I guess. It looked disgusting. During an interview on 8/12/25, at 12:35 p.m. NA Employee E2 stated The residents were supposed to get Chicken [NAME] and all they got…

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

Based on observations and resident and staff interviews it was determined that the facility failed to provide residents food products based on their preferences for two of two nursing units (The Gardens, and Scenic Heights).Findings include: During an observation on 8/12/25, at 12:30 p.m. Nurse Aide (NA) Employee E2 brought a lunch tray to The Gardens Nurses Station and stated to Unit Clerk (UC) Employee E3 Look at this. They did it again. State Agency inquired as to the what the problem was, and NA Employee E2 stated They gave Resident R2 minced and pureed food, and she is on a regular diet. They do this all the time. Review of Resident R2's clinical record revealed a physician's order dated 11/18/24, for a regular diet. During an observation on 8/12/25, at 12:28 p.m. UC Employee E3 placed a call while on speaker phone to the Dietary Department to inform them that the wrong food was provided to Resident R2. The call was answered with a recording of The person at this extension is unavailable. The call did not leave an opportunity or an ability to leave a message for the Dietary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to properly monitor weight and nutrition status by failing to address weight loss for one of three residents (Residents R1).Finding include: Review of the facility policy, Weight Monitoring dated 1/7/25, indicated that a weight monitoring schedule will be developed upon admission for all residents. Weights should be recorded at the time obtained. Monitor weight monthly. A significant change in weight is defined as: 5% change in weight in 1 month7.5% change in weight in 3 months10% change in weight in 6 months Review of Resident R1's admission record indicated admission to the facility on 9/19/24, and readmitted on [DATE]. Review of Resident R1's Minimum Data Set (MDS-periodic assessment of care needs) assessment dated [DATE], included diagnoses of high blood pressure, hyperlipidemia (high fat in the blood) and low back pain. Review of Resident R1's clinical record revealed that weight were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interviews, it was determined that the facility failed to the notify resident representative of a change in condition or care for one of three residents (Resident R1). Findings include: Review of facility policy Notification of Changes: dated 1/7/25, indicated that the facility will promptly inform the resident, and notifies the resident's representative when there is a change requiring notification which include circumstances that require a need to alter treatment. This may include new treatment or discontinuation of treatment. For competent individuals the facility must still notify the resident's representative, if known. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/18/25, included diagnoses of high blood pressure, sepsis (a life-threatening reaction to an infection), and muscle weakness. Review of Resident R1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility documents, observations, and staff interviews, it was determined that the facility failed to maintain a homelike environment on two of two nursing floors (Second floor). Findings include: A review of facility policy Safe and Homelike Environment dated 1/7/25, indicated that housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Review of a Resident Representative concern dated 4/8/25, stated that There was poop all over the walls in her bathroom. Review of a Resident Representative concern dated 4/9/25, stated that On the third floor you have a broken faucet in the 'spa' area. During an observation in room [ROOM NUMBER] bathroom on 4/29/25, at 2:29 p.m. the walls behind the toilet and sink had multiple areas with chipped paint and dark brown stains. During an interview on 4/29/25, at 2:42 p.m. Director of Plant Operations Employee E11 confirmed the above findings. During an observation on the Third Floor Spa…

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 observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of residents for one of three residents reviewed (Resident R1), relating to use of an insulin pump (wearable device that delivers insulin continuously to people with diabetes). Findings include: Review of the facility policy Comprehensive Care Plans dated 1/7/25, indicated that the comprehensive, person-centered care plan included measurable objectives and time frames, to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified to meet the resident's needs. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of care needs) dated 3/30/25, indicated diagnoses of heart failure (heart doesn't pump blood as…

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 policy, observation, and staff interview, it was determined that the facility failed to properly maintain kitchen equipment and one unit pantry in a sanitary condition creating the potential for cross contamination and food-borne illness (Main Kitchen and 3rd floor). Findings include: A review of facility policy Sanitation Inspection, dated 1/7/25, indicated that it is the policy of the facility to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations. During an observation on 3/17/25, at 10:03 a.m., a tour of the walk-in cooler in the main kitchen conducted with Food Services Director (FSD) Employee E16, revealed that the cold air condenser fan covers (2 total) and the ceiling immediately forward of these cooler fans had a build-up of dust, grime, and debris. FSD Employee E16 confirmed observation by surveyor when viewed. During an interview on 3/17/25, at 10:05 a.m., FSD Employee E16 confirmed that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, documentation, observations, resident and staff interviews and state and federal guidance it was determined that the facility failed to fully implement COVID monitoring, tracking, and testing in accordance with state and federal guidance for outbreak response, placing residents at risk for potentially acquiring communicable disease, failed to follow enhanced barrier precautions for one of three residents reviewed (Residents R51), and failed to prevent cross contamination during a medication pass for one of three residents (Resident R88). Findings include: Review of the facility policy Infection Prevention and Control Program dated 1/7/25, indicated the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines, to include a system of surveillance.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for three of three residents (Resident R26, R37, and R56 ). Findings include: Review of facility policy Call Lights: Accessibility and Timely Response last reviewed 1/7/25, indicated all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. Process for responding to call lights: a. Turn off the signal light in the resident's room. b. Identify yourself and call the resident by name. c. Listen to the residents' request and respond accordingly. Inform the resident if you cannot meet the need and assure him/her that you will notify the appropriate personnel. d. Inform the appropriate personnel of the resident's need. e. Do not promise something you cannot deliver. f. If assistance is needed with a procedure, summon help by using 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 policy and documentation, resident and staff interview it was determined that the facility failed to respond the residents concerns from resident council for five of six month reviewed (September, October, November and December of 2024, and February of 2025). Findings include: Review of facility policy Resident and Family Concerns/Grievances dated 1/7/25, indicated : The Grievance Official is responsible for overseeing the grievance process; receiveing and tracking grievances through to their conclusion, leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident. Review of facility documentation resident council notes indicated the following concerns: 6/12/24: call bells(a problem answered timely), meal trays late, alternate (for meals - ability to receive). 7/12/24: call bells takes up to an hour for a response, snack cart and meal trays late. 8/14/24: snack cart not taken around. 9/11/24: snack cart is hit or miss. 10/9/24: snack…

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, resident and staff interview it was determined that the facility failed to provide ongoing program of activities to meet the interest of and support the physical, mental, and psychosocial well-being of each resident for four of four residents: Findings include: Review of activity calendar for March 17th through March 21, 2025, revealed: Bible study: Manicures: Observations on 3/19/25, at 10:30 a.m. bible study was on the activity calendar observations in the activity room at 10:40 a.m. Showed two residents watching a movie in the activity room. Resident group interview on 3/19/25, at 3:00 p.m. residents indicated that the activities program was not meeting their needs. -Residents stated that they do not consistenly get together for activities or resident council. - Residents stated that they can't always gather for activities due to COVID. -Residents requested to re- start activites from February resident council meeting and this had not been met. -Residents indicated they wanted to do activities to include: going outside, going to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, and interview, the facility failed to develop an individualized care plan for the use of a urinary catheter (insertion of a tube into the bladder to remove urine) for one of six residents (R64) and failed to provide privacy for the collection bags for four of six residents reviewed (Residents R32, R34, R51, and R64). Findings include: Review of facility policy Comprehensive Care Plans dated 1/7/25, indicated it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meets professional standards of quality. Review of the facility policy Catheter Care dated 1/7/25, indicated it is the policy of this facility to ensure that residents with indwelling catheters receive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to identify and address significant weight loss in a timely manner for one out of seven residents (R38), failed to develop or update an individualized nutrition care plan for two out of seven residents (R1 and R38), and failed to timely assess the nutritional status of four out of seven residents (Residents R1, R9, R38, and R64). Findings include: Review of facility policy Nutritional Management dated 1/7/2025, indicated a comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change in condition. Follow-up assessments will be completed as needed. The assessment shall clarify the resident's current nutritional status and individual risk factors for altered nutrition/hydration. The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care. Interventions will be individualized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care related to oxygen and nebulizer management for four of four residents (Residents R15, R36, R80, and R84). Findings include: Review of the facility's Oxygen Concentrator policy dated 1/7/25, indicated nursing is responsible to change oxygen tubing and mask/nasal cannula (a thin tube that delivers oxygen into the nose) weekly, and as needed if it becomes soiled or contaminated. Change nebulizer tubing and delivery devices weekly. Keep delivery devices covered in plastic bags when not in use. Clean filters per manufacturer's recommendations. Review of the clinical record indicate Resident R15 was admitted to the facility on [DATE]. Review of Resident R15's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 2/28/25, indicated diagnoses of hypertension (high blood pressure), diabetes (high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident observations, and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three of five days (3/10/25, 3/17/25, and 3/18/25). Findings Include: Review of the facility policy Nursing Services and Sufficient Staff dated 1/7/25, indicated it is the policy of the facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Review of the admission record indicated Resident R80 admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/28/25, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), End Stage Renal Disease (kidneys cease to function on a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and interview with staff, it was determined that the facility failed to make certain that PRN (as needed) orders for psychotropic medications are limited to 14 days for three of five residents (Residents R30, R32, and R41). Findings include: Review of the facility policy Use of Psychotropic Medications dated 1/7/25, indicated all PRN psychotropic medications, excluding anti-psychotic drugs will have a time limitation of 14 days duration for orders. The exception indicated orders may be extended beyond 14 days if the prescriber believes that it is appropriate for the PRN order to be extended and must document their rationale in the medical record. No exceptions for antipsychotic drugs, they are limited to 14 days and cannot be renewed without explanation and a new order. Psychotropic medications must have a diagnosed specific condition and indication for use. Review of Resident R30's admission record indicated she was admitted on [DATE]. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals properly and securely in three of six medications carts (Grandview medication cart, Riverside medication cart and Rosewood medication cart) and failed to properly secure treatment medication in one of four treatment carts (Fourth floor Rosewood hall treatment cart) and failed to secure one of two medication rooms (fourth floor medication room). Findings include: Review of the facility policy Medication Storage in the Facility last reviewed 8/1/24, indicated medications and biologicals are stored safely, securely, and properly, following manufactures recommendations or those of the supplier. During an observation on 3/17/25, at 9:55 a.m. the treatment cart was in the Riverview hallway next to room [ROOM NUMBER] unsecured, unattended and accessible to any passerby. During an observation on 3/17/25, at 11:18 a.m. the treatment cart was in the Riverview hallway…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documents, and staff interviews, it was determined that the facility failed to notify the physician of a change in treatment in a timely manner for one of three residents (Resident R290). Findings include: Review of facility policy Notification of Changes dated 1/7/25, indicated the purpose of this policy is to ensure the facility promptly informs the residents, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident's physician when there is a circumstance that require a need to alter treatment. Review of the clinical record revealed that Resident R290 was admitted to the facility on [DATE], with diagnoses of high blood pressure, depression, and non-Alzheimer's dementia (the loss of memory and other intellectual functions severe enough to cause problems in one's abilities to perform their usual personal, social, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical record, documentation provided by the facility, and staff interview it was determined that the facility failed to report an allegation of possible neglect within 24 hours to the local state field office for one of seven residents (Resident R30). Findings include: Review of facility policy Abuse Neglect, and Exploitation last reviewed 1/7/25, indicated the facility will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse and neglect. An immediate investigation is warranted when suspicion of abuse, or neglect occurs. It was indicated all persons, including witnesses, and others who might have the knowledge of the allegation must be identified and interviewed. A complete and through documentation of the investigation must be conducted. The facility will have written procedures that include reporting of all alleged violations to the Administrator,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to conduct a thorough investigation of an incident to rule out possible neglect for one of seven residents (Resident R30). Findings include: Review of facility policy Abuse Neglect, and Exploitation last reviewed 1/7/25, indicated the facility will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse and neglect. An immediate investigation is warranted when suspicion of abuse, or neglect occurs. It was indicated all persons, including witnesses, and others who might have the knowledge of the allegation must be identified and interviewed. A complete and through documentation of the investigation must be conducted. Review of the facility policy Incidents and Accidents last reviewed 1/7/25, indicated the facility staff will report, investigate, and review any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to document assessment and notify the physician of a change in condition for one of four residents (Resident R80). Findings include: Review of the facility policy Notification of Changes dated 1/7/25, indicated the facility will promptly inform the resident, consult the resident's physician, and notify the resident's representative when there is a change requiring notification. Review of the admission record indicated Resident R80 admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/28/25, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), End Stage Renal Disease (kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), and high blood pressure. Review of Resident R80's physician order dated 2/24/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observation, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to prevent further decrease in range of motion for one of four residents (Resident R32). Findings include: Review of the Code of Federal Regulations (CFR) §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Review of the admission record indicated Resident R32 was admitted to the facility on [DATE]. Review of Resident R32's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/6/25, indicated the diagnoses of non-Alzheimer's dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), anxiety, and high blood pressure. Review of Resident R32's physician order dated 2/11/25, indicated right resting hand splint (positions…

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 policy and clinical records, staff and resident interview, it was determined that the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for one of three residents (R290). Findings include: Review of the clinical record revealed that Resident R290 was admitted to the facility on [DATE], with diagnoses of high blood pressure, depression, and non-Alzheimer's dementia (the loss of memory and other intellectual functions severe enough to cause problems in one's abilities to perform their usual personal, social, or occupational activities.) Review of Resident R290's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/9/25, indicated diagnoses were current. Review of Resident R290's physician order dated 3/14/25, indicated to administer one liter of 5-0.45% Dextrose-Sodium Chloride (solution for fluid and electrolyte replenishment and caloric supply) at 50 milliliters/hour…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident clinical records, facility policy and staff interview, it was determined the facility failed to provide care and services for the provision of hemodialysis (treatment that helps body remove extra fluid and waste products) consistent with professional standards of practice for one of two residents (Resident R80). Findings include: Review of the facility policy Hemodialysis dated 1/7/25, indicated the facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. The facility will coordinate and collaborate with the dialysis facility to assure that the resident's needs related to dialysis treatments are met. Documentation requirements are met to assure that treatments are provided as ordered by the physician. Review of the admission record indicated Resident R80 admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/28/25, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one of six residents reviewed (Resident R30). Findings include: Review of the facility Dementia Care policy last reviewed 1/7/25, indicated it is the policy of the facility to provide the appropriate treatment and services to every resident who displays signs of or is diagnosed with dementia, to meet his or her highest practicable, physical, and psychosocial well-being. Review of the facility policy Incidents and Accidents last reviewed 1/7/25, indicated the facility staff will report, investigate, and review any accidents or incidents that occur on facility property and may involve a resident. Licensed staff will report incidents/accidents and assist with completion of any investigative information to identify root cause. Incidents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon clinical record review, and staff interview, it was determined that the facility failed to ensure that any irregularities submitted in the medication regiment reviews (MRR) by pharmacy were acted upon for one out of five residents (Resident R30). Findings include: Review of the facility Use of Psychotropic Medication(s) policy dated 8/21/24, indicated it is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. A psychotropic drug is any drug that affects brain activities associated with mental processes and behaviors. Psychotropic drugs include, but are not limited to the antipsychotics, antidepressants, anti-anxiety, and hypnotics. Residents who use psychotropic drugs shall receive gradual dose reductions, unless contraindicated, in an effort to discontinue these drugs. The effects of the psychotropic medications on a resident's physical, metal, and psychosocial well-being will be evaluated…

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 the facility failed to obtain laboratory services as ordered for one of two residents (Resident R290). Findings Include: A review of the facility Laboratory Services and Reporting reviewed 1/7/25, indicated the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The facility must provide or obtain laboratory to meet the needs of its residents. The facility is responsible for the timeliness of the service. A review of the facility Provision of Physician Ordered Services last reviewed 1/7/25, indicated the facility will provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. The facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician orders. Review of the clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for two of three residents (Resident R15 and R30). Findings include: Review of the facility policy Coordination of Hospice Services dated 8/21/24, last reviewed 1/7/25, indicate when a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident ' s highest practicable physical, mental, and psychosocial well-being. Guidelines include but not inclusive to: 1. The facility maintains written agreements with hospice providers that specify the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding the resident's care. 2. The facility will communicate with hospice and identify, communicate, follow…

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 policy, plan of correction for previous incident, resident records and staff interview it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively addressed concerns identified during an elopement (2/6/25). Findings include: The facility Quality assessment and assurance committee policy last reviewed on 1/7/25, indicated that the facility will maintain a QA committee to identify quality issues and develop appropriate plans of action to correct quality deficiencies. Review of the facility policy Elopements and Wandering Residents dated 1/7/25, indicated that the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations and staff interview, it was determined that the facility failed to determine it was safe to self-administer medications for one of five residents (Resident R1). Findings include: Review of the facility policy Resident Self-Administration of Medication dated 1/7/25, indicated a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/2/25, indicated diagnoses of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), and high blood pressure. Section C0500 indicated a Brief Interview for Mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, and interview, the facility failed to have physician order specifications relating to size of indwelling catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine) for one of five residents (Resident R4) and failed to provide privacy for the collection bags for three of five residents reviewed (Residents R4, R5, and R6). Findings include: Review of the facility policy Catheter Care dated 1/7/25, indicated it is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when in use. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Review of admission record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/18/25, indicated diagnoses of neurogenic bladder (lack of bladder control due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide medications within time guidelines for one of five residents reviewed (Resident R5). Findings Include: Review of the facility policy Nursing Services and Sufficient Staff dated 1/7/25, indicated it is the policy of the facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Review of admission record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), stroke (damage to the brain from an interruption of blood supply), and hemiplegia (paralysis of one side of the body). Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, facility documents and staff interview it was determined the facility failed to ensure that residents were free from any significant medication errors for two of two residents (Residents R2 and R3). Findings include: Review of facility policy Medication Administration dated 1/7/25, indicated ensure the six rights of medication administration are followed: the right resident, the right drug, the right dosage, the right route, the right time, and the right documentation. Identify resident by photo in the Medication Administration Record (MAR). Compare medication source with the MAR to verify resident name, medication name, form, dose, route, and time. Review of the facility policy Medication Errors dated 1/7/25, indicated it is the policy of the facility to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Significant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for three of five residents reviewed (Residents R5, R6, and R7). Findings include: Review of the facility policy Enhanced Barrier Precautions dated 1/7/25, indicated enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities. A physician order will be obtained for residents with any of the following: wounds, indwelling medical devices (i.e. central lines and urinary catheters). Review of admission record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of renal insufficiency (condition where the kidneys lose the ability to remove waste and balance…

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 maintain a clean homelike environment on five of six nursing units (lilac lane, rosewood, riverview, hilltop, and grandview) Findings Include: Review of the facility policy Safe and Homelike Environment last reviewed 1/7/25, indicates the facility will provide a safe, clean, comfortable and homelike environment. Housekeeping and maintenance service will be provided as necessary to maintain a sanitary, orderly and comfortable environment. During a facility tour complete on 1/28/25, 10:00 a.m. thru 10:30 am. the following observations were noted: . Third floor lilac lane hallway the ceiling cold air return vents were coved in a dark grey fuzzy substance. . Third floor rosewood hallway the ceiling cold air return vents were coved in a dark grey fuzzy substance and had visible cobwebs hanging down. . Fourth floor riverview hallway ceiling light covers were noted having a blackish substance, some of the ceiling panels were drooping down; some ceiling tiles were missing pieces and others were spotted…

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

Based on review of facility documentation and staff interview it was determined that the facility failed to maintain and implement an effective Quality Assurance and performance improvement program that focuses on outcome by failing to implement a QAPI for the call bell system pager use. Findings include: Review if the facility policy Call Bells: Accessibility and Timely Response last reviewed 1/7/25, indicates call bells will directly relay to a staff member or centralized location to ensure appropriate response. Ensure the call system alerts staff members directly or goes to a centralized staff work area. Review of the facility documents dated 10/3/19, stated the following: A permanent exception is granted to upgrade the nurse call system to eliminate the dome lights above each resident room door. Documentation submitted indicates that there are kiosks placed throughout both neighborhoods and at each nurses' station. The system chimes when a call bell is activated, and the room number shows on the kiosk as well as shows red when an active call light is occurring. In addition, each…

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

Based on review of facility policy, facility document, staff interviews, and observations, it was determined that the facility failed to ensure that the call bell system was in full working order for six of six units (lilac lane, vineyard, rosewood, riverview, hilltop, and grandview) by ensuring employees were in possession of a pager as indicated in the exemption dated 10/3/19. Findings include: Review of the facility policy Call Bells: Accessibility and Timely Response last reviewed 1/7/25, indicates that call bells will directly relay to a staff member or centralized location to ensure appropriate response. Review of the facility documents dated 10/3/19, stated the following: A permanent exception is granted to upgrade the nurse call system to eliminate the dome lights above each resident room door. Documentation submitted indicates that there are kiosks placed throughout both neighborhoods and at each nurses' station. The system chimes when a call bell is activated, and the room number shows on the kiosk as well as shows red when an active call light is occurring. In addition,…

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 interviews, it was determined that the facility failed to ensure a clean, sanitary, functional environment in the laundry room storage area and the large main storage area located on the facilities lower level. Findings include: Review of the facility policy Safe and Homelike Environment last reviewed 1/7/25, indicates housekeeping and maintenance service will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Review of Appendix PP of the State Operational manual §483.90(i) Other Environmental Conditions: The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. During an observation completed on 1/28/25, at 10:05 a.m. of the lower-level laundry storage area it was discovered that the center of the floor contained two large puddles of water. The right corner of the room was roped off with caution tape. The storage area contained shelves that included but not inclusive to numerous uncovered pillows, 31 boxes of briefs in assorted sizes, as well as floor…

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

Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by maintaining an acceptable water temperature throughout resident areas for two of two units on the same boiler line (Third and Fourth floors) and failed to have disposable wash cloths immediately available for staff use for two of two units (Third and Fourth floors). Findings Include: Review of the facility policy Safe and Homelike Environment dated 8/21/24, indicated the facility will provide and maintain bed and bath linens that are clean and in good condition. Housekeeping and Maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Review of the facility policy Emergency Water Supply dated 8/21/24, indicated in the case of hot water loss, the facility will follow these guidelines: Have a supply of disposable wash wipes to provide baths. During a tour of the facility on 12/17/24, at 9:05 a.m. the staff were noted to be stating there's not any water…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation and staff and resident interviews, it was determined that the facility failed to maintain mechanical systems (boiler system), and three of three facility elevator cars (Two cars on Main, and one car on service elevator) in a safe operating condition resulting in no hot water being available for resident hygiene on two of two units (Third and Fourth floors) and residents unable to the leave the floors (Third and Fourth floors) unless in the event of a necessary medical reason where they would have to be carried down flights of stairs on a bed sled (an emergency type device used to transport residents up and down stairs who are not able to safely navigate on their own). Findings include: Review of Code of Federal Regulations §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. Interview on 12/17/24, at 9:18 a.m. Plant Operations Manager Employee E5 indicated, the facility does not have hot water at this time. Interview…

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 ensure that nursing staff have the specific competencies and skill sets necessary to provide care for resident bathing for five of five nursing staff (Licensed practical Nurse (LPN) Employee E2, Nurse Aide (NA) Employee E1, NA Employee E4, NA Employee E7, and NA Employee E8). Findings include: Review of Code of Federal Regulations §483.35 Nursing Services. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to…

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

Based on observations and resident and staff interviews, it was it was determined that the facility failed to obtain physician's orders for one of two residents (Resident R1) and failed to revise/update a comprehensive care plan to meet resident care needs for one of two residents (Resident R1). Findings include: Review of facility policy Medication Administration dated 8/21/24, indicates medications are administered by licensed nurses, or other staff who are legally authorized to do so as ordered by physician. Review of the facility policy Resident Self-Administration of Medications dated 8/21/24, indicates it is the policy of this facility to support each resident ' s right to self-administer medication. Residents ' preference will be documented on the appropriate form and placed in the medical record. Review of the facility policy Comprehensive Care Plans dated 8/21/24, indicated it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes…

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

Based on review of facility policies, observations and staff interview, it was determined the facility failed to cover food products and properly serve food in a sanitary manner to prevent foodborne illness. Findings include: A review of the facility policy Food Safety Requirements dated 8/21/14, indicated food will be stored, prepared, distributed and served in accordance with professional standards for food safety. Food safety practices shall be followed throughout the facility ' s entire food handling process. Foods and beverages shall be distributed and served to residents in a manner to prevent contamination. Strategies that include but are not limited to covering all foods when traveling a distance (i.e., down a hallway, to a different unit or floor). During an observation on 11/19/24, at 12:20 p.m. Dietary Aid Employee E9 entered the elevator on the first floor with a cart containing three lunch trays, the trays contained brownies that were uncovered and were delivered to the fourth floor. During an interview completed on 11/19/24, at 12:22 p.m. Dietary Employee E9 confirmed…

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, resident interviews, observation, and staff interviews, it was determined that the facility failed to provide prompt assistance to meet residents care needs for five of nine residents who require care (Residents R1, R2, R3, R4, and R5) Findings included: Review of facility policy Resident Rights last reviewed 5/31/24, indicated that residents must be free from mental, physical, and sexual abuse and exploitation, neglect, finical exploitation and involuntary seclusion. A resident shall be treated with dignity and respect. A resident shall receive assistance in accessing health care services. During an interview with Resident R1 on 11/6/24, at 10:49 a.m. the following was stated: A couple of times I had to wait a couple hours for them to answer my call light. One time a nurse came in to give me medication after I had my call light on for about an hour, and I told her that I needed my aide to help me to the restroom and I had to wait another hour for my aide. I peed myself while I waited. During an interview on 11/6/24, at 11:04 a.m. Resident R2 stated 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 policy, facility document, staff interviews, and observations, it was determined that the facility failed to ensure that the call bell system was in full working order for one of six resident hallways (Lilac Lane) Findings include: Review of the facility policy Call Bells: Accessibility and Timely Response dated 5/31/24, indicated that call bells will directly relay to a staff member or centralized location to ensure appropriate response. Review of the facility documents dated 10/3/19, stated the following: A permanent exception is granted to upgrade the nurse call system to eliminate the dome lights above each resident room door. Documentation submitted indicates that there are kiosks placed throughout both neighborhoods and at each nurses' station. The system chimes when a call bell is activated, and the room number shows on the kiosk as well as shows red when an active call light is occurring. In addition, each nursing team member will carry a pager that notifies them directly of an activated call bell. The pager will show the room number and the bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of three residents with facility-initiated transfers (Resident R2, R3, and R4). The findings include: Review of the facility policy Transfer and Discharge, dated 5/31/24, indicated that when a resident is transferred to another provider for any reason, the following information must be provided to the receiving provider: a) Contact information of the practitioner, who was responsible for the care of the resident. b) Resident representative information c) Advanced directive information d) All information necessary to meet resident's needs such as medications, diagnoses, allergies, resident status, most relevant labs, test results, e) All special instructions for ongoing care such as treatments and risks. f) Resident's plan of care Review of the clinical record indicated Resident R2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident/resident representative and/or the representative of the Office of the State Long-Term Care Ombudsman of resident transfers, in writing, to include to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman for three of three resident records reviewed (Resident R2, R3, and R4) Findings Include: Review of the facility policy Transfer and Discharge dated 5/31/24, indicated that the facility will provide copies of notices for emergency transfers to the Ombudsman. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/7/24, indicated diagnoses of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of three resident hospital transfers (Resident R2, R3, and R4). Findings Include: Review of the facility policy Transfer and Discharge, dated 5/31/24, indicated that the facility will provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/7/24, indicated diagnoses of high blood pressure, hyponatremia (low sodium levels in the blood), and hypokalemia (low potassium levels in the blood). Review of Resident 2's clinical record revealed that the resident was transferred to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, facility documents and staff interview it was determined the facility failed to ensure that residents were free from any significant medication errors for one of two residents. (Resident R1). Findings include: Review of facility policy Medication Administration dated 5/31/24, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Compare medication source (such as, bubble pack and vials). Ensure that the six rights of medication administration are followed: - Right resident - Right drug - Right dose - Right route - Right time - Right documentation Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/16/24, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical record, documentation provided by the facility, and staff interview it was determined that the facility failed to report an allegation of neglect within 24 hours to the local state field office for one of two residents (Resident R1). Findings include: The facility's policy Abuse, Neglect and Exploitation dated 5/31/24, indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Possible indicators of abuse, neglect and exploitation include but are not limited to, failure to provide care needs such as feeding, bathing, dressing, turning and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff interview, it was determined that the facility failed to maintain a clean, safe, and homelike environment in six of six resident rooms, one of two shower rooms and one of three hallways (Residents R2, R6, R11, R25, R36, R43 and Fourth-floor shower room, Fourth-floor hallway be elevator). Findings Include: Review of the facility policy Safe and Homelike Environment dated 5/31/24, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment, and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Review of the admission record indicated R6 admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/26/24, indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), hypertension (high blood pressure) and peripheral vascular disease (a condition in which narrowed blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for six of six months (January 2024 - June 2024), failed to implement enhance barrier precautions for one of three residents (Residents R27), failed to prevent cross contamination during a dressing change for one of three residents (Resident R27), failed to prevent cross contamination during a medication pass for two of three residents (Residents R33, R47), failed to have appropriate isolation signage posted for one of three residents (Resident R88), failed to utilize soiled utility area appropriately, and failed to provide evidence of control measures and testing protocols for water management prevention program for six of six months (January 2024 -June 2024). Findings include: Review of the facility policy Infection Prevention and Control Program…

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

Based on review of facility documents, resident interviews, meal tray observations and staff interviews, it was determined that the facility failed to provide palatable meals during lunch for two of two meal observations (Lunch on 6/3/24 and 6/4/24). Findings include: During lunch observations on 6/3/24, at 12:45 p.m. of the fourth floor dining room, the drink cooler revealer twelve out of twelve apple juice containers that were frozen. Hot tea and coffee were served out of foam cups. During lunch observations on 6/3/24, at 1:25 p.m. Resident R94 lunch tray found a salad with French fries appearing not fully cooked. During an interview on 6/3/24, at 1:25 p.m. Resident R94 stated I have frozen pudding and the salad is frozen cold! During an interview on 6/3/24, at 1:31 p.m. Registered Nurse (RN) Employee E6 stated: Resident R94's French fries do not look done and her apple juice is frozen. During a resident council group interview on 6/5/24, at 1:59 p.m. two out of four residents stated that the food is tasted bad. During an interview on 6/6/24, at 10:30 a.m. Dietary Manager Employee…

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

Based on a review of facility policy, documents, resident medical records and staff interviews it was determined that the facility failed to notify the resident's physician and responsible party of unavailable medication prescribed for one of three residents. (Resident R1) Findings include: A review of facility policy Unavailable Medications dated 1/27/22, revealed that when medication is unavailable the facility is to notify the resident's physician of the inability to obtain the medication. The facility is to obtain alternative treatment orders and or specific orders for monitoring the resident while the medication is on hold. A review of facility Concern Form dated 6/27/23, revealed that Resident R1's granddaughter filed a concern that based on a conversation with her grandmother the facility failed to administer the resident's insulin as prescribed by the physician on 6/24/23, and 6/25/23. A review of facility Coachable Moments dated 6/27/23, revealed that Licensed Practical Nurse (LPN) Employee E1 confirmed that insulin was unavailable and that the resident's physician was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of resident medical records and staff interviews it was determined that the facility failed to implement person centered care plans for two of four residents. (Resident R 2 and R4) Findings include: A review of Resident R2's medical records revealed that the resident was readmitted to the facility on [DATE], with the diagnosis of end sage renal disease, epilepsy, chronic pain syndrome, muscle weakness and dependence on renal dialysis, A review of Resident R2's September 2023 electronic medication administration record (EMAR) revealed that the resident was prescribed a pain medication to be administered as needed (prn) every 12 hours for pain. The EMAR also indicated that prior to the administration of prn pain medication the nurse staff was to attempt a non pharmacological intervention and document the effectiveness. Further review of Resident R2's September 2023 EMAR revealed that Resident R2 received prn pain medication on 9/1/23, 9/2/23, 9/6/23, 9/12/23, and 9/13/23. A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a a review of resident medical records and staff interviews it was determined that the facility failed to make certain an as needed (prn) pain medication was necessary by failing to attempt and document the effectiveness of non pharmacological interventions prior to the administration of the pain medication for two of two residents. (Resident R2 and R4). Findings include: A review of Resident R2's medical records revealed that the resident was readmitted to the facility on [DATE], with the diagnosis of end sage renal disease, epilepsy, chronic pain syndrome, muscle weakness and dependence on renal dialysis, A review of Resident R2's September 2023 electronic medication administration record (EMAR) revealed that the resident was prescribed a pain medication to be administered as needed (prn) every 12 hours for pain. The EMAR also indicated that prior to the administration of prn pain medication the nurse staff was to attempt a non pharmacological intervention and document the effectiveness. Further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, facility documents, resident medical records and staff interviews it was determined that the facility failed to provide proper medication administration and reaction monitoring for two of three residents as required. (Residents R1 and R3) Finding include: A review of facility policy Unavailable Medication dated 1/27/22, indicated that the facility will notify the resident's physician when a change in treatment occurs and will obtain new treatment orders and or orders for specific reaction monitoring, A review of Resident R1's medical record revealed that the resident was admitted to the facility on [DATE], with the diagnosis of diabetes, malaise, anxiety and depression. A review of facility Concern form and follow up dated 6/27/23, revealed that the facility failed to administer the resident resident's insulin on 6/24/23, and 6/25/23. The follow up documentation indicated that the resident's physician was not notified to obtain new orders for treatment and or specific orders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility documents, resident medical records and staff interviews it was determined that the facility failed to make certain that documentation of resident medication administration was recorded accurately for one of four residents. (Resident R1) Findings include: A review of Resident R1's medical record indicated that the resident was admitted to the facility on [DATE], with the diagnosis of diabetes, malaise, anxiety and depression. A review of facility Concern Form and Coachable Moment dated 6/27/23, revealed that Licensed Practical Nurse (LPN) Emplyee E1 falsely documented the administration of insulin to Resident R1 on 2/24/23. A review of Resident R1's electronic medication administration Record (EMAR) June 2023 revealed the LPN Employee E1 recorded on Resident R1's medication record that the residen was administered insuline on 6/24/23 while this is inaccurate. LPN Employee E1 confirmed that the document was inaccurate. During an interview on 10/16/23, at 2:56 pm. the Director 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.