Quality Life Services - Sarver

Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for the facilities Automated External Defibrillator (AED-a portable, electronic device designed to diagnose and treat life-threatening cardiac arrhythmias) and crash cart (a supply cart used in an emergency).Findings include: Review of facility AED policy dated 10/13/25, indicated the AED will be available for use in emergency situations and its function maintained according to manufacturer recommendations. Daily maintenance includes checking the indicator to ensure that it is green (AED is ready for rescue). Perform maintenance to the AED monthly. During an observation of the facilities AED box on 11/12/25, at 12:05 p.m. revealed an AED with electrodes attached to the machine were present. An extra set of electrodes were in the AED box. The facility failed to provide documentation for the daily and monthly checks to ensure the AED is in working order. During an observation of the facilities crash…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 education documents, and staff interview, it was determined that the facility failed to provide training on effective communication for one of five staff members (Nurse Aide (NA) Employee E3).Findings include:Review of facility provided documents and training records for NA Employee E3 on 11/14/25, indicated that NA Employee E3 was hired to the facility on 7/12/17, and failed to include education on effective communication as required.Interview on 11/14/25, at 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on effective communication for one of five staff members (NA Employee E3). 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(6)(d) Staff development.

Based on a review of facility policies, documents, resident medical records, and staff interviews it was determined that the facility failed to identify and determine the root cause of a physical injury as the potential for abuse or neglect for one of 59 residents. (Resident R1) Findings include: A review of facility Resident Protection from Abuse, Neglect, Mistreatment or Exploitation policy dated 11/21/24, revealed that serious physical injuries are to be reported to the state agency, investigated and PB 22s completed for each alleged perpetrator. A review of the facility's documents revealed that on 2/16/25, Resident R1 sustained a serious physical injury while being transferred from her bed to a wheelchair. While pivoting during the transfer procedure the resident heard and felt a loud crack in her right shoulder. Due to the resident's increased pain and edema to her right hand the facility obtain a physician order for an xray. The xray revealed a displaced 2.2 X 1.3 centimeter avulsion fracture of the lateral aspect of the humeral head in the right shoulder. Resident R1 was…

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

Based on a review of facility policies, documents, resident medical records and staff interviews, it was detrmined that the facility failed to implement an abuse and neglect policy to properly investigation of a physical injury or unknown origin for one of 59 residents (Resident R1). Finding include: During a review of facility Resident Protection from Abuse, Neglect, Mistreatment or Exploitation date 11/21/24, it was revealed that the facility is to implement and complete an investigation for serious physical injury that has resulted in pain, and impairs physical functioning temporally or permanently. The results of the investigation including reports and PB22s must be completed with in five working days. During a review Resident R1's progress notes it was revealed that on 2/16/25, the resident sustained a serious physical injury of unknown origin resulting from transfer procedures from her bed to a wheelchair. While pivoting during the transfer procedure the resident heard and felt a loud crack in her shoulder resulting in pain and edema of her right hand. A hospital emergency…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident clinical records, investigation documents and staff interview, it was determined that the facility failed to report injuries of unknown source for three of three residents (Resident R1, R2, and R3) reviewed. Findings include: Review of facility policy Resident Protection from Abuse, Neglect, Mistreatment or Exploitation, dated 11/21/24, indicated that nursing homes treat all residents with kindness, respect and in a manner that is at all times free from any form of abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our resident, each home will implement procedures in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action. All reports of abuse, neglect, exploitation or mistreatment including injuries of unknown source, and misappropriation of resident property will be investigated and documented. The Administrator or Director of Nursing will notify the PA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 grievances for 60 days, resident and staff interviews, it was determined that the facility failed to effectively resolve and provide responses to residents and/or their responsible parties in a timely manner in relation to concerns documented via Grievance procedure and complete the reports in their entirety for one of three grievances reviewed. Findings include: Review of facility policy Communication of Resident, Family and Staff Concerns and Grievances dated 8/17/23, indicated to encourage residents, family members and staff to ask questions and express their concerns will maximize their quality of care and promote higher levels of staff and customer satisfaction through timely responses to questions and resolution of issues concerns and grievances. Once we receive a grievance, we will make every effort to respond as quickly and effectively as we can with the goal of always providing outstanding customer service. Our goal is to resolve all concerns within five days of the report with all parties in agreement of the resolution, If 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 record review and staff interview, it was determined that the facility failed to notify a physician of abnormal glucose levels as per physician's order for two out of five residents (Residents R20 and R33). Findings include: Review of the facility policy Physician Notification dated 12/1/23, indicated upon identification of a resident who has clinical changes, change in condition, or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to physician as indicated. Review of the facility policy Hypoglycemia Protocol dated 12/1/23, indicated for hypoglycemia (a blood glucose less than or equal to 70 mg/dl (milligrams/deciliter), and hyperglycemia a more common side effect, should recheck the blood sugar and notify the physician. Review of Resident R33's admission record indicated an admission date of 5/9/23, with diagnoses of renal insufficiency (condition where the kidneys lose the ability to remove waste 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, clinical record review, facility provided documents, and staff interview, it was determined that the facility failed to thoroughly investigate a potential allegation of abuse/neglect for misappropriation of property for one of two residents reviewed (Resident R37). Findings include: Review of facility policy Resident Protection From Abuse, Neglect, Mistreatment or Exploitation dated 12/1/23, indicated misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Abuse, neglect, misappropriation of property and exploitation will be identified through various methods including reports from employed or contracted staff. All reports of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property will be investigated and documented. All investigations will be conducted thoroughly and will attempt to gather as much factual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of seven residents sampled with facility-initiated transfers (Residents R28, R34, and R40). Review of facility policy Medical Emergency dated 12/1/23, indicated if transfer is required, complete transfer form and send appropriate documentation with the resident. Findings include: Review of the clinical record indicated Resident R28 was admitted to the facility on [DATE]. Review of Resident R28's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/25/24, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and pain in left hip. Review of the clinical record indicated Resident R28 was transferred to hospital on [DATE] and returned to the facility on [DATE]. Review of Resident R28's clinical record revealed no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for five of five residents (Residents R20, R28, R34, R40, and R67). Findings include: Review of the clinical record indicated Resident R28 was admitted to the facility on [DATE]. Review of Resident R28's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 6/25/24, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and pain in left hip. Review of the clinical record indicated Resident R28 was transferred to hospital on [DATE] and returned to the facility on [DATE]. Review of Resident R28's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of Long-Term Care Ombudsman for the hospitalization on 12/12/23. 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 review of facility policy, clinical record review, 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 five of five resident hospital transfers (Residents R20, R28, R34, R40, and R67). Review of facility policy Bed Holds dated 12/1/23, indicated upon transfer out, nursing will provide a copy of the Notice to the resident. Review of the clinical record indicated Resident R28 was admitted to the facility on [DATE]. Review of Resident R28's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 6/25/24, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and pain in left hip. Review of the clinical record indicated Resident R28 was transferred to hospital on [DATE] and returned to the facility on [DATE]. Review of Resident R28's clinical record failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records and staff interview, it was determined that the facility failed to update a care plan for one of eight residents (Resident R123) to accurately reflect the current status of the resident. Findings include: Review of clinical record indicated Resident R123 was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), hypertension and hypercholesterolemia (high amounts of cholesterol in the blood). Review of Resident R123's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 9/25/24, indicated the diagnoses remain current. Review of Resident R123's physician orders dated 9/17/24 indicated a 1800 milliliter (ml) fluid restriction. Review of Resident R123's Resident Care Plan Summary Report (report nurse aides used to know what kind of care to provide) dated 9/17/24, revealed no fluid restriction. During an interview on 9/26/24, at 1:30 p.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident interview and observations, clinical record review, and staff interview it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of five residents observed (Resident R39). Findings include: The facility policy Activities of Daily dated 12/1/23, indicated a program of ADL's (eating, dressing, hygiene, elimination, and ambulation) will be provided to prevent disability and maintain resident's functional abilities. A program of assistance and instruction in ADL skills is implemented. Review of the admission record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/22/24, indicated the diagnoses of high blood pressure, 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 legally blind. Section B1000 Vision - severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to provide appropriate care and services for one of two residents receiving intravenous therapy (Resident R34) and failed to monitor resident wounds and complete weekly skin assessments for two of five residents (Residents R37 and R52). Review of facility policy Midline Dressing Changes dated 12/1/23, indicated midline catheter (a thin, flexible tube that is inserted into a large vein in the upper arm, used to safely administer medication into the bloodstream) dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way. Label with initials, date and time. Review of facility policy Overview of IV Therapy 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.

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 assess pressure ulcers for two of three residents (Residents R2 and R60). Findings include: Review of the facility policy Skin Integrity and Wound Management - NU17 dated 12/1/23, indicated perform wound assessment and complete proper forms upon initial identification of altered skin integrity, weekly, and with any deterioration of the wound. Review of Resident R2's admission record indicated admission to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/23/24, indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and depression. Review of Resident R2's clinical progress note Weekly Skin and Wound Note dated 9/10/24, indicated a pressure related wound to sacrum/coccyx/anal area was found acquired in-house on 7/10/14; Current measurements indicated length 1.0…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure appropriate treatment and services were provided for two of two residents (Residents R25 and R34) with an indwelling urinary catheter (a tube inserted in the bladder to drain urine). Review of facility policy Indwelling Urinary Catheter dated 12/1/23, indicated the catheter bag should have a privacy cover applied at all times unless it has one built in by the manufacturer. Review of the clinical record indicated Resident R25 was admitted to the facility on [DATE]. Review of Resident R25's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/25/24, indicated diagnoses of obstructive uropathy (structural hindrance of normal urine flow), heart failure (heart doesn't pump blood as well as it should), and high blood pressure. Section H indicated an indwelling catheter was present. Review of Resident R25's current physician orders indicated a Coude catheter (a type 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, observations, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for three of four residents (Residents R33, R34, and R40). Review of facility policy Oxygen Therapy via Nasal Cannula dated 12/1/23, indicated to replace cannula every seven days, date and store in plastic bag when not in use. Review of the admission record indicated Resident R33 was admitted to the facility on [DATE]. Review of Resident R33's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/5/24, indicated diagnoses of renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), heart failure (heart doesn ' t pump blood as well as it should), and high blood pressure. Review of Resident R33's current physician orders indicated change nasal cannula and protective covers weekly. Every night shift every Tuesday, for prevention. CPAP (a continuous positive airway pressure machine used…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to have accurate physician's orders for two of four residents with assist rails (Residents R25 and R26) and conduct ongoing accurate assessments for one of three residents (Resident R33). Findings include: Review of the facility policy Side Rail Evaluation NU16.55 dated 12/1/23, indicated the side rail evaluation will be completed upon admission, re-admission, or significant change. The facility will obtain a physician order for the side rail. The facility will develop a plan of care for the side rail use. Resident R25 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/25/24, indicated diagnoses of obstructive uropathy (structural hindrance of normal urine flow), heart failure (heart doesn't pump blood as well as it should), and high blood pressure. Review of Resident R25's physician orders on 9/26/24, 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 facility policy, clinical record review, controlled drug shift count record, and staff interview, it was determined that the facility failed to implement pharmacy procedures for the reconciliation of controlled drugs for one of two medication carts (Pennsylvania Medication Cart). Findings include: Review of facility policy Management of Controlled Drugs dated 12/1/23, indicated to destroy the drug with another licensed staff member as witness. Staff member designated as witness to the destruction must actually witness the waste. Document the reason for the destruction on the controlled drug inventory in the space for that dose. Signature of person who poured and destroyed the drug and signature of witness must be entered in the space with the documentation of the destruction. Perform a complete count of all controlled drugs at the change of shifts or at any time in which narcotic keys are surrendered from one staff member to another. Count must be performed by two licensed nurses per state…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record reviews, and staff interview it was determined that the facility failed to accurately document education and immunization administration related to pneumococcal vaccines for one of five residents (Resident R26). Findings include: Review of the facility policy Standing Orders for Administering Pneumococcal Vaccine to Adults dated 12/1/23, indicated identify adults in need of vaccination with pneumococcal vaccine. Screen all patients for contraindications to pneumococcal vaccine. Provide all patients with a copy of the most current federal Vaccine Information Statement (VIS). Administer the vaccination per order and record in the medical record the date, the manufacturer and lot number, the site and route, and the name of person administering it. Resident R26 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/23/24, indicated diagnoses of heart failure (heart doesn't pump…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records and staff interview, it was determined that the facility failed to update a care plan for one of four residents (Resident R1) to accurately reflect the current status of the resident. Findings include: Review of the facility policy Comprehensive Care Plan dated 12/1/23, indicated an interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on as needed basis with changes. Review of the facility policy Elopement Prevention dated 12/1/23, indicated should the resident's behavior warrant elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) prevention measures, a comprehensive elopement prevention plan will be documented as part of the care plan. Staff observations will be noted during the resident's stay and modifications will be made to the care plan and prevention techniques. Review of the admission record indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records, observations, and staff interviews it was determined that the facility failed to make certain each resident received adequate supervision that resulted in one elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of four residents (Resident R1). Findings include: Review of the facility's policy Elopement Prevention dated 12/1/23, indicated the receptionist will maintain the list of all residents at risk for elopement, including name and room number. This list will be distributed to the management team of the care community with staff members who may be in contact with those residents. Departments include nursing, therapeutic recreation, housekeeping, and maintenance. Review of the facility's policy Accidents and Incidents dated 12/1/23, indicated the purpose of the policy is to promote a safe environment for all residents. Review of the admission record indicated Resident R1 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, personnel files and staff interview it was determined that the facility failed to complete required training on dementia management, communication, and behavioral interventions for five out of five nurse aide personnel files (Nurse aide- NA Employee E1, NA Employee E2, NA Employee E3, NA Employee E4, and NA Employee E5). Findings include: The facility assessment dated [DATE], indicated that staff competencies are necessary to provide the level and types of care needed for the resident population. Annual mandatory education consist of test to determine competency. Education is formal and informal and includes dementia management, communication and behavioral interventions. Review of Nurse aide Employee E1's personnel record on 11/8/23, at 11:30 a.m. did not include an annual in-service training on dementia, communication, or behavioral interventions. Review of Nurse aide Employee E2's personnel record on 11/8/23, at 11:32 a.m. did not include an annual in-service training 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 facility policy review, resident observations and interviews, clinical record review and staff interviews, it was determined that the facility failed to make certain a physician order for use of and cleaning of a Bi-PAP/CPAP machine (machines used to make breathing easier), failed to develop a plan of care for two of three resident (Resident R25 and R212), and failed to properly date respiratory equipment and administer at the appropriate rate of flow for one of three residents (Resident R214). Findings include: Review of the policy CPAP/BIPAP dated 8/17/23, indicated CPAP/BIPAP will be initiated by physician order. To clean the CPAP system: -CPAP, Mask and Whisper Swivel, PRN for soiling: -unplug the unit. Do not immerse unit in liquid or allow liquid to enter the unit, -using a cloth slightly dampened with water and mild dish detergent, wipe the outside of the CPAP case, -let the CPAP dry before reconnecting to power source, -gently wash the mask/swivel in a solution of warm water and a mild soap 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 observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct accurate assessments to ensure that bed rails were used to meet residents' needs and the risks associated with bed rail usage for two of three residents (Resident R5, and R42). Findings include: Review of the facility policy Side Rail Evaluation dated 8/17/23, indicated the following evaluation will be initiated to determine the appropriateness of the use of side rails. The purpose is to determine the least restrictive device to be used to promote the highest level of functionality and to identify and risk factors involved with its use. Review of the clinical record indicated that 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 10/2/23, indicated diagnoses of Multiple Sclerosis (MS - the immune system eats away at protective covering of nerve cells), chronic obstructive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to implement measures to care for huber needles (a specially designed hollow needle used with a med port (a surgically placed intravenous access and the needle has a long, beveled tip that can go through your skin as well as the silicone septum of the implanted port's reservoir) for two of two residents (Residents R13 and R214). Findings include: Review of facility policy Catheter Insertion and Care dated 8/17/23, indicated only specially designed non-coring (utilized to gain access to infusion port) safety needles are to be used when accessing an implanted port. These needles are to be changed every five to seven days or upon suspicion of contamination. For daily maintenance use SASH (Saline-administration-saline-heparin) one pre-filled 10 ml (milliliter) barrel size syringe containing 5ml normal saline, one pre-filled 10ml barrel size syringe of heparin (a blood thinner) 100units/ml. Review…

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