Sayre Health Care Center

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate clinical documentation for 1 of 18 residents reviewed (Resident 4).Findings include: Review of Resident 4's medical history revealed a diagnosis list that included the following: heart failure, iron deficiency anemia, vitamin d deficiency, and gastrointestinal hemorrhage (bleeding). The current care plan for Resident 4 revealed the resident is at nutritional risk due to medical history, fluctuating weights, and variable intakes. An intervention included weigh per physician order for close monitoring. Review of the current physician orders for Resident 4 revealed no physician order for weight assessment as noted in the care plan. Dietary documentation for Resident 4 dated February 18, 2026, at 11:34 AM revealed that a reweight was completed with weight gain now noted (significant for 90 and 180 days). The documentation noted to follow with request for weekly weights for close monitoring. Facility documentation titled, Provider Notification Form, 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 closed clinical record review, review of facility documents, and staff interview, it was determined the facility failed to ensure the necessary resident information was documented by the physician to facilitate a facility-initiated transfer of a resident to another facility for one of one resident reviewed for a facility-initiated transfer (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss), and was discharged to another skilled nursing facility on September 30, 2025, due to the facility documentation indicating the resident needs could not be met at the facility. Review of facility documents dated October 7, 2025, (after the resident was discharged ) completed by the Director of Nursing, noted that on September 23, 2025, the resident's responsible party was present for a care plan meeting with social services, and the resident care coordinator and the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed clinical record review, review of facility documents, and staff interview, it was determined the facility failed to provide a written notice of transfer before discharge to a resident's responsible party for a facility-initiated discharge for one of one resident reviewed for a facility- initiated discharge (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility on [DATE], and was discharged to another skilled nursing facility on September 30, 2025. Review of facility documents dated October 7, 2025, (after the resident's discharge) revealed facility staff conducted meetings on September 23, 2025, and September 26, 2025, with Resident CR1's responsible party to review resident behaviors in the facility including multiple elopement (leave the facility unattended) attempts, falls, wandering into other resident rooms, touching staff and other residents, removing clothing in common areas, and a sexual incident with another…

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

Based on observation and staff interview, it was determined that the facility failed to store, prepare, and serve food in a manner to prevent the potential spread of foodborne illness in the main kitchen and the facility's pantry for one of two nursing units (Unit 1 Nursing Unit). Findings include: According to HACCP (Hazard Analysis and Critical Control Points) to avoid the potential for food borne illness, food must be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit within two hours, and from 70 degrees Fahrenheit to 41 degrees Fahrenheit or lower in the next four hours. Before cooling food, reduce the quantity or size of the food you are cooling by dividing large food items into smaller portions. Observation and review of the facility's cool down logs with Employee 4, certified dietary manager, on March 4, 2025, at 10:39 AM revealed that facility staff documented the following on February 28, 2025: At 9:45 AM staff cooked four beef rounds and initiated cooling them down for food service at a later date. The beef rounds temperatures were documented as 178 degrees…

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 honor advance directive choices for one of 24 residents reviewed (Resident 175). Findings include: Clinical record review for Resident 175 revealed that on [DATE], the resident's responsible party indicated that the resident was a full code (staff was to start CPR [Cardiopulmonary Resuscitation]). On February 27, 2025, Resident 175's responsible party completed a POLST (Physician Orders for Life-Sustaining Treatment, a form directing medical staff to complete life-sustaining treatment or allow a natural death) form and a facility code status form (a form directing life-sustaining care) both which indicated Do Not Resuscitate (DNR) for Resident 175. Resident 175's code status form was also signed by the physician on February 27, 2025. There was no documentation that the facility changed Resident 175's code status order from full code to DNR until [DATE]. The above information was reviewed during an interview on…

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

Based on clinical record review and staff interview, it was determined that the facility failed to provide the required notification to a resident whose payment coverage changed for one of three residents reviewed (Resident 2). Findings include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. A review of the Form Instructions Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 revealed that examples of the common reasons why an extended care stay, or services may not be covered under Medicare might include the beneficiary no longer requires daily skilled care for a medical condition but wants to continue residing in the skilled nursing facility (SNF). The SNF enters a good…

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 provide a clean, comfortable, and homelike environment on one of two nursing units reviewed (Nursing Unit 2; Residents 24, 50, and 54). Findings include: Observation of Resident 24's room on March 4, 2025, at 12:54 PM; and March 7, 2025, at 12:45 PM revealed a six-foot section of wall located under the resident's window that had a large, black colored linear stain and marring in various areas. Observation with the Nursing Home Administrator (NHA) of an egress area leading outside to the laundry building on March 6, 2025, at 11:17 AM revealed multiple partially smoked cigarette butts discarded on the ground. A concurrent interview with the NHA revealed it was unclear who the cigarette butts belonged to since the facility is non-smoking. The above information for Resident 24's room and the egress area was reviewed in a meeting with the Nursing Home Administrator on March 7, 2025, at 12:38 PM. Observation of the Unit 2 Nursing Unit on the following dates and times revealed: On March 4, 2025, 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 the facility policy, employee personnel records, and staff interview, it was determined that the facility failed to develop and implement an abuse prohibition policy that required a thorough investigation of prospective employee's employment history for one of five newly hired employees reviewed (Employee 7). Findings include: The policy entitled Abuse Policy and Procedure last reviewed without changes on June 13, 2024, revealed that the facility will protect the residents from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will not apply and employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law. All potential employees are screened for a history of abuse, neglect, and misappropriation of property by completing a state criminal background on all prospective employees and if not a resident of the state (where the facility was located) for two consecutive years, an FBI (Federal Bureau of Investigation) check will be conducted. Review 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 clinical record review and staff and resident interview, it was determined that the facility failed to develop and implement a comprehensive care plan for two of 18 residents reviewed (Residents 44 and 5). Findings include: Interview with Resident 44 on March 4, 2025, at 11:56 AM revealed that two staff provided her assistance to complete her most recent shower ,and they were, slam bam, with the shower care. Resident 44 denied that staff were abusive, but she confirmed that she did not appreciate the approach staff used when providing her care. Review of electronic Task Documentation (electronic system for nurse aides to document the provision of care) dated February 2025, revealed that Employee 3 (nurse aide) documented Resident 44 received a shower on Friday evening, February 28, 2025. Interview with Employee 3 on March 5, 2025, at 2:25 PM revealed that she remembered Resident 44's shower experience on February 28, 2025. Employee 3 stated that another nurse aide, Employee 6, asked her to witness Resident 44's shower care because Resident 44 was known to make false…

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 closed clinical record review and staff interview, it was determined that the facility failed to provide a discharge summary with the necessary components for one of three closed records reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed nursing documentation dated January 6, 2025, at 4:28 PM that Resident CR1 was discharged to home with home health services. Further review of the closed clinical record for Resident CR1 revealed wound care documentation dated January 3, 2025, that noted the resident had a Stage 3 Pressure Ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue) to the sacrum (a bone at the base of the spinal column). Closed record review for Resident CR1 revealed a document titled, Resident Discharge Summary, dated January 6, 2025. The document was signed by the resident's responsible party and the discharging nurse. The discharge summary did not include anything about the resident's wound, consultation, or recommended treatment by wound care. 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 clinical record review and resident and staff interview, it was determined that the facility failed to provide care and services to maintain or improve the ability to perform activities of daily living for two of five residents reviewed for rehabilitation concerns (Residents 5 and 44). Findings include: An interview with Resident 5 on March 4, 2025, at 11:18 AM revealed that she has been doing her own exercises and is currently not in therapy. A review of the task documentation (located in the electronic health record where staff document specific care related events for a resident) for Resident 5 revealed a restorative nursing program (RNP) dated March 3, 2025, that noted the following: RNP Sit to Stands: with use of grab bars resident to come to a standing position, hold for a count of 10, and sit for 10. Nursing documentation for Resident 5 dated March 3, 2025, at 9:37 AM revealed the resident is starting on a new RNP program. An occupational therapy discharge summary for Resident 5 dated February 4,…

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

Based on clinical record review and staff interview, it was determined that the facility failed to implement physician orders for two of 18 residents reviewed (Residents 52 and 21). Findings include: Clinical record review for Resident 52 revealed documentation by the facility's consultant optometrist (healthcare provider who specializes in eye care and vision services) dated January 21, 2025, that the provider evaluated Resident 52 for blurry vision in her right and left eyes. The provider diagnosed that Resident 52 had dry eye syndrome (tears are unable to provide adequate lubrication of the eye) of bilateral lacrimal glands (gland above the eye that produces tears), which was described as significant. The plan was to treat Resident 52 with one drop of artificial tears solution in both eyes twice a day. Resident 52's clinical record contained no evidence that staff implemented the eye care professional's directive to start artificial tears twice daily. Interview with the Nursing Home Administrator on March 7, 2025, at 9:22 AM confirmed that the facility failed to implement…

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 closed clinical record review and staff interview, it was determined that the facility failed to provide recommended interventions, that are consistent with professional standards of practice, to promote healing of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident CR1). Findings include: Closed record review for Resident CR1 revealed the resident was admitted to the facility on [DATE]. The resident was discharged on January 6, 2025. Nursing documentation upon admission for Resident CR1 dated December 27, 2024, at 6:01 PM revealed the resident had a Skin tear one centimeter in size to sacrum (a bone at the base of the spine). An admission assessment for Resident CR1 titled Admit/Readmit Screener V2, dated December 27, 2024, at 6:27 PM revealed skin integrity documentation that assessed the resident as having moisture associated skin damage (MASD, damage to the skin caused by moisture), to the sacrum with measurements noted as one centimeter (cm) by 0.25 cm. Medical provider…

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

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for two of two residents reviewed (Residents 36 and 54). Findings include: According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag. Clinical record review for Resident 54 revealed a current physician's order for staff to provide oxygen at 2 liters per minute (LPM) via NC (nasal canula, tubing to deliver oxygen to the nose) continuously every shift, to change the oxygen tubing every Saturday night, label and date the new tubing for infection control, and make sure all tubing and nebulizer equipment (to help administer medication to the lungs) was bagged…

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

Based on clinical record review and staff and resident interview, it was determined that the facility failed to provide behavioral health interventions for a resident to maintain the highest practicable mental well-being for one of two residents reviewed for behavioral concerns (Resident 44). Findings include: Clinical record review for Resident 44 revealed an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated December 13, 2024, that assessed that Resident 44 exhibited behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Interview with Resident 44 on March 4, 2025, at 11:56 AM revealed that two staff provided her assistance to complete her most recent shower, and they were slam bam, with the shower care. Resident 44 denied that staff were abusive but confirmed that she did not appreciate the…

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

Based on observation and staff interview, it was determined that the facility failed to securely store medications on one of two nursing units (Unit One dining room); and failed to ensure medication labeling for one of seven residents observed for medication administration (Resident 46). Findings include: Observation of a medication administration pass on March 5, 2025, at 9:01 AM revealed Employee 2 (licensed practical nurse, LPN) prepared medications for administration to Resident 46. Employee 2 crushed Resident 2's Rosuvastatin (medication used to lower cholesterol) 10 mg (milligram) tablet and administered the medication to Resident 46. The medication resource Drugs.com stipulated that a consumer should swallow a Rosuvastatin tablet whole. Interview with Employee 2 on March 5, 2025, at 9:10 AM confirmed that she crushed Resident 46's Rosuvastatin medication. Employee 2 verified that there were no instructions on the medication labeling from the pharmacy that stipulated one should not crush the medication, and she was not aware of the precaution. Interview with Employee 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to obtain dental services for one of four residents reviewed for dental concerns (Resident 52). Findings include: Interview with Resident 52 on March 5, 2025, at 9:29 AM revealed that she utilized a partial dental plate to fill in the gap in her top teeth; however, that partial no longer fit. Resident 52 indicated that there were discussions regarding the replacement of the partial (between her son, the facility, and a dental provider), but she did not know if or when she would receive a new one. Observation of Resident 52 during the interview revealed that she had several missing front teeth. Clinical record review for Resident 52 revealed that Medicaid was a payer for her care as of August 23, 2024. Nursing documentation dated November 15, 2024, at 10:14 PM revealed that Resident 52 complained of left-sided dental pain. Staff assessed that the left side of Resident 52's face had visible…

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

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier transmission-based precautions for one of 18 residents reviewed (Resident 75) Findings include: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Review of the facility policy titled, Infection Prevention Control 2024 Plan, last reviewed without changes on June 13, 2024, revealed that EBP are an infection control intervention…

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 select facility policy and procedures, observation, and staff interview, it was determined that the facility failed to follow established procedures of water storage to ensure that water is available to essential areas when there is a loss of normal water supply for two of two nursing units (Unit 1 and Unit 2). Findings include: A review of the facility policy titled, Water Availability, last reviewed without changes on [DATE], revealed that the facility will ensure water availability to essential areas when there is a loss of normal water supply. Further review of the policy revealed that, This water will be rotated on a regular basis. Observation of a storage area on Nursing Unit 1 across from the main dining area on [DATE], at 9:56 AM revealed a large shelving unit that held multiple cardboard boxes. Each cardboard box contained six gallons of water. A concurrent interview with Employee 8, medical records and human resources, revealed the boxes containing the gallons of water were the…

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

Based on clinical record review and staff interview it was determined that the facility failed to provide the required notification timely to a resident whose payment coverage changed for two of three residents reviewed (Residents 58 and 83). Findings include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when…

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, the facility failed to maintain an environment free of potential accident hazards in the beauty shop. Finding: Observation of the facility on April 17, 2024, at 11:31 AM revealed that the beauty shop door was open, and no employees were in the beauty shop. Further observation of the beauty shop revealed there was a large bottle of shampoo, conditioner, and hair color, all with warning labels. There were also two pairs of hair-cutting shears, a razor, a curling iron plugged in, and warm to the touch, and a tart burner with hot melted liquid. The surveyor tested the temperature of the water the in hair washing station revealing the water was 121.6 degrees Fahrenheit. The hairdresser returned to the beauty shop at 11:56 AM. Interview with Employee 4 (beautician) on April 17, 2024, at 11:56 AM revealed that she was in a resident's room doing their hair. She stated that she also transports the residents to and from the beauty shop and she wasn't aware that she needed to secure the beauty shop when leaving. 28 Pa. Code 211.12(d)(1)(5) Nursing…

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 maintain food service equipment in a sanitary manner and proper working order in the facility's main kitchen. Findings include: An observation in the facility's main kitchen on April 16, 2024, at 10:06 AM revealed the following: The hood system (exhaust vent panels) over the stove/cooktop area contained thick visible dust buildup throughout. Observation of the dishwasher on April 16, 2024, at 10:18 AM revealed that the dishwasher was running to clean breakfast dishes. The dishwasher gauge revealed the wash temperature was 126 degrees Fahrenheit. There was no sanitizing agent connected to the dishwasher. Employee 5 (dietary manager) acknowledged the low wash cycle on the dishwasher. Review of the kitchen's Dish Machine Temperature Log revealed the wash temperature was not meeting the required temperature since March 31, 2024. The log noted, If temps of the dishwasher wash cycle fall below 150 degrees notify the dietary manager and maintenance.Dish Further review of the Dish Machine Temperature…

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 select facility policies and procedures, observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier transmission-based precautions for three of 18 residents reviewed (Residents 23, 20, and 51); and ensure hygienically clean resident laundry processing in the main laundry. Findings include: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device…

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 select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care for a resident with an indwelling central line catheter for one of 18 residents reviewed (Resident 20). Findings include: The surveyor requested any policy pertaining to the care and services of a peripherally inserted central catheter (PICC, long, thin, tube that is inserted through a vein in the arm and passed through to a larger vein near the heart. The line requires careful care and monitoring for complications including bleeding, infection, and blood clots.) during interviews with the Nursing Home Administrator and the Director of Nursing on April 17, 2024, at 2:00 PM, and April 18, 2024, at 2:00 PM. The policies provided by the facility entitled, Removal of Central Venous Catheter, and I.V. (Multilumen CVC), last reviewed without changes on June 20, 2023, did not address the development of a plan of care, limb restriction measures (e.g., avoid blood pressures in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff and resident interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of five residents reviewed for mood/behavior (Resident 32). Findings include: Clinical record review for Resident 32 revealed a diagnosis of Chronic Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) since admission on [DATE]. During an interview with Resident 32 related to his diagnosis of PTSD on April 16, 2024, at 10:37 AM revealed that loud noises and bright lights trigger him. Resident 32 stated that loud noises startle him related to his time in combat. A review of Resident 32's admission minimum data set (MDS, an assessment completed by the facility at intervals to determine care needs) assessment dated [DATE], indicated PTSD was an…

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

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of one resident reviewed (Resident 31). Findings include: Clinical record review for Resident 31 revealed the facility admitted him on March 30, 2023, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 31's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated March 27, 2023, indicated that the facility assessed Resident 31 as having a diagnosis of dementia and determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 31's current care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss, which should reflect family involvement 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 clinical record review and staff interview, it was determined that the facility failed to ensure the consultant pharmacist reviewed the drug regimen of each resident and reported any irregularities to the attending physician monthly for two of five residents reviewed for potentially unnecessary medications (Residents 26 and 24). Findings include: Clinical record review for Resident 26 revealed a Medication Regimen Review document (form the facility utilizes to document the monthly medication regimen review by the consultant pharmacist) that indicated the consultant pharmacist identified a potential medication irregularity that Resident 26 should be evaluated for a gradual dose reduction of her antianxiety medication, Xanax, on November 26, 2023. The same Medication Regimen Review document indicated that the consultant pharmacist identified that Resident 26 should be evaluated for a gradual dose reduction of her antidepressant medication, Effexor, on December 26, 2023. Resident 26's clinical record did not contain evidence that a physician received the report pertaining 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 observation, clinical record review, review of select manufacture's guidelines, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 24 and 132). Findings include: The facility's medication error rate was 7.69 percent based on 26 medication opportunities with two medication errors. Review of the package insert for the BD AutoShield Duo safety pen needle, dated June 2014, indicates that when using the safety pen needle, the needle should be checked to ensure it is attached correctly by dialing up two units of insulin, pointing the pen up, and pressing the thumb button. If liquid does not appear, change the needle, and repeat the steps. If liquid is present, then users are directed to then dial up the prescribed dose of insulin. Observation of a medication administration pass on April 16, 2024, at 11:45 AM revealed Employee 1, licensed practical nurse, preparing to administer Insulin Aspart Flexpen (type of insulin to treat diabetes) to Resident 132. Employee 1 attached the safety pen needle, then…

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 select facility policies and procedures, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure the administration of a COVID-19 immunization for one of five residents reviewed for immunization concerns (Resident 45). Findings include: The facility, COVID19 Immunization/Booster Informed Consent, is a form utilized by the facility to document the provision of education regarding the risks and benefits of the vaccine, the resident's history of previous vaccinations, and documentation of consent by the resident/resident's responsible party for the administration of the vaccine. The facility policy entitled, Core Infection Prevention and Control Measures, last revised October 23, 2023, revealed that the facility will provide residents and their family/POA information on the COVID vaccines on admission and will be given the opportunity to receive the vaccine in the facility. Residents will be educated on the current recommended vaccine through the CDC and will be offered the vaccine at least yearly or with any new…

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, clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to perform an accurate assessment for possible entrapment with the use of specialized mattress and side rails for one of six residents reviewed (Resident 51). Findings include: The policy entitled Side Rail Policy and Procedure, last reviewed on June 20, 2023, indicates that when side rail usage is deemed appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment. The policy does not specify what the facility will utilize when the assessments would indicate that side rails are not appropriate or safe. Observation of Resident 51's bed on April 17, 2024, at 10:37 AM revealed that her bed had bilateral half side rails up on each side of her bed. Resident 51 had an air mattress in place that easily shifted side to side leaving a larger gap between the side rail and the mattress depending on what side…

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.