Aurora Nursing And Rehab Center

Based on review of facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent. Findings include: Review of a facility policy for administering medications dated September 24, 2025, included that the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication, and the individual administering the medication initials the resident's medication administration record on the appropriate line after giving each medication and before administering the next one. Observations made during medication administration on December 15 and 16, 2025, revealed that two medication administration errors were made during 26 opportunities for error, resulting in a medication administration error rate of 7.69 percent. Physician's orders for Resident 9, dated November 12, 2025, included for the resident to have one…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending November 19, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending December 17, 2025, identified repeated deficiencies related to accuracy of Minimum Data Set (MDS) assessments (mandated assessment of a resident's abilities and care needs), the development of individualized care plans, care plan timing and revision, and preventing issues with the accountability of controlled medications…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Older Adults Protective Services Act, facility policies, information provided by the facility and residents' clinical records, as well as staff interviews, it was determined that the facility failed to report timely allegations of abuse to the State Survey Agency (Department of Health) and to other state agencies in accordance with state law for three of 30 residents reviewed (Residents 131, 132, 133). Findings include: The Older Adults Protective Services Act, 1997-13, Section 701 (a)(1)(2), indicated that it was mandatory to report to the Protective Services agency. An employee or an administrator who has reasonable cause to suspect that a recipient is a victim of abuse shall immediately make an oral report to the agency. If applicable, the agency shall advise the employee or administrator of additional reporting requirements that may pertain under subsection (b). An employee shall notify the administrator immediately following the report to the agency. Within 48 hours of making the oral…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative in writing of the transfer and reason for hospitalization for seven of 30 residents reviewed (Residents 1, 5, 9, 14, 22, 23, 24.). This deficiency was cited as past noncompliance. Findings include: A nursing note for Resident 1, dated February 5, 2024, at 1:39 p.m., revealed that Resident 1 was being admitted to the hospital for osteomyelitis. There was no documented evidence that a written notice of Resident 1's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer. Nursing notes for Resident 5, dated September 26, 2024, at 3:06 a.m. and 5:36 a.m., revealed that the resident had a change in mental status with increased confusion, garbled speech, and bad chest pain. The physician was notified and the resident was sent to the hospital for evaluation. She was admitted to the hospital with chest pain, fever, abdominal pain, altered mental status, and leukocytosis…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to administer medications and obtain weights as ordered by the physician for two of 30 residents reviewed (Residents 5, 17). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated October 9, 2024, revealed that the resident was moderately cognitively intact, required assistance from staff for daily care needs and had diagnoses that included heart failure. Physician's orders for Resident 5, dated October 7, 2024, included an order for the resident to receive 5 milligrams (mg) of Midodrine (a medication that treats low blood pressure) three times a day for hypotension (low blood pressure) and was to be held if the systolic blood pressure (the top number in a blood pressure reading) was greater than 130 millimeters of mercury (mmHg). A review of Resident 5's Medication Administration Record (MAR) for October and November 2024 revealed that staff administered the 5 mg of Midodrine when the…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 30 residents reviewed (Residents 12, 22, 26). Findings include: The facility's policy regarding the administration of oral medications, dated December 7, 2023, indicated that the nurse was to document all medications administered to each resident on the resident's medication administration record (MAR). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated September 19, 2024, indicated that the resident was understood and could understand others, required assistance with daily care needs, received antianxiety and opioid medications, was receiving oxygen therapy and hospice services, and had a diagnosis of congestive heart (the heart cannot pump blood well enough to meet the body's needs). Physician's orders for Resident 12, dated September 11, 2024, included an order for 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 the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required timeframe for four of 30 residents reviewed (Residents 181, 182, 183, 184). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that an admission MDS assessment was to be completed no later than 14 days (admission date + 13 calendar days) following admission. A comprehensive admission MDS assessment for Resident 181, dated July 29, 2024, revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on August 7, 2024, which was 16 days after…

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 Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for four of 30 residents reviewed (Resident 10, 11, 18, 29). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to have a completion date (Section Z0500B) that was no later than the ARD plus 14 calendar days. A quarterly MDS assessment for Resident 10 had an ARD of August 9, 2024, which was 93 days after the previous quarterly MDS assessment with an ARD of May 8,…

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 Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 30 residents reviewed (Residents 5, 22, 23). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2024, revealed that Section N0415J1 Hypoglycemic Medications was to be coded if the resident took hypoglycemic medication during the seven-day look-back period and Section N0415K1 was to be coded if the resident took anticonvulsant medication during the seven-day look-back period Physician's orders for Resident 5, dated October 3, 2024, included orders for the resident to receive 500 milligrams (mg) of Metformin (medication used to lower blood sugars) one time a day for diabetes. There was no physician's order for the resident to receive an anticonvulsant medication. Review of the Medication…

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

Based on clinical record reviews 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 one of 30 residents reviewed (Resident 5). Findings include: A facility policy for Comprehensive Person-Centered Care Plans, dated December 7, 2023, included that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated October 9, 2024, revealed that the resident was moderately cognitively impaired, was always incontinent of urine, and received an antibiotic. Physician's orders, dated July 24, 2024, included orders for the resident to receive 100 milligrams…

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 polices and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 30 residents reviewed (Resident 16). Findings include: A facility policy for Comprehensive Person-Centered Care Plans, dated December 7, 2023, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16, dated September 10, 2024, indicated that the resident was cognitively intact, was understood and able to understand others, required assistance with care needs, received dialysis (treatment to remove extra fluid and waste from…

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

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that interventions were in place to prevent urinary tract infections for one of 30 residents reviewed (Resident 15) who had an indwelling urinary catheter. Findings include: The facility's policy regarding indwelling urinary catheters (a flexible tube inserted and held in the bladder to drain urine), dated December 7, 2023, revealed that indwelling urinary catheters would be used sparingly, for appropriate indications only. If an indwelling urinary catheter was needed, staff would monitor for and report complications such as evidence of symptomatic infection. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated October 30, 2024, revealed that the resident was cognitively intact and had an indwelling urinary catheter. A diagnosis record, dated November 2024, revealed the resident had a diagnosis of urinary retention. Physician's orders for 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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure there was a physician's order to receive dialysis for one of 30 residents reviewed (Resident 16) who required dialysis. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16, dated September 10, 2024, indicated that the resident was cognitively intact, was understood and able to understand others, required assistance with care needs, received dialysis (treatment to remove extra fluid and waste from the blood when the kidneys are not able to), and had a diagnosis of end-stage renal disease (ESRD - kidneys no longer work as they should, requiring dialysis or kidney transplant). A review of Resident 16's clinical record and dialysis communication records revealed that the resident received dialysis treatment every Monday, Wednesday, and Friday. A care plan for Resident 16, dated December 21, 2023, indicated that the resident received dialysis services; however, there was no documented…

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

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications, by failing to ensure that non-pharmacological (non-medication) behavioral interventions (individualized, non-pharmacological approaches to care), were attempted prior to the administration of as needed antianxiety medications for one of 30 residents reviewed (Resident 12). Findings include: The facility's policy regarding psychotropic medications (any medication that affects brain activities associated with mental processes and behavior), dated December 7, 2023, indicated that non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated September 19, 2024, indicated that the resident was cognitively intact, 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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed, resulting in significant medication errors for one of 30 residents reviewed (Resident 15). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated October 30, 2024, revealed that the resident was cognitively intact, received an anticoagulant (blood thinner), and had diagnoses that included atrial fibrillation (an abnormal heart rhythm). Physician's orders for Resident 15, dated October 25, 2024, included an order for the resident to receive 3 milligrams (mg) of warfarin (blood thinning medication) daily for atrial fibrillation. However, the resident's Medication Administration Record for October 25, 2024, revealed that staff did not administer 3 mg of warfarin daily as ordered. Physician's orders, dated October 28, 2024, included an order for the resident to receive 6 mg of warfarin at bedtime then 3 mg of warfarin on Tuesday October 29, 2024.…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for the State Survey and Certification (Department of Health) survey ending December 20, 2023, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending November 14, 2024, identified repeated deficiencies related to a failure to develop comprehensive care plans, to update resident care plans, to follow physician's orders, to account for controlled medications, and following proper infection control practices. The facility's plan of correction for a deficiency 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 established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for two of 31 residents reviewed (Residents 9, 14). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant…

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, as well as staff interviews, it was determined that the facility failed to maintain an effective preventative maintenance program for the walk-in-freezer. Findings include: Observations of the walk-in-freezer on November 12, 2024, at 9:26 a.m. and November 13, 2024, at 12:18 p.m. revealed that there was an accumulation of ice on the ceiling extending out from the condenser to the other side of the walk-in-freezer, as well as from the ceiling and extending down the four side walls, and multiple areas on the floor with an accumulation of ice. Interview with the Dietary Manager on November 13, 2024, at 12:18 p.m. confirmed that there was an accumulation of ice on the ceiling extending out from the condenser to the other side of the walk-in-freezer, as well as from the ceiling and extending the down the four side walls, and multiple areas on the floor with an accumulation of ice. Interview with the Director of Maintenance on November 13, 2024, at 12:25 p.m. revealed that he has been there six months and does not recall having the walk-in freezer worked on.…

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

Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on effective communication to nursing and other direct care staff for four of four employee files reviewed (Nurse Aide 5, Nurse Aide 6, Licensed Practical Nurse 7, Registered Nurse 8). Findings include: The facility's Facility Assessment (an assessment completed by the facility to thoroughly assess the needs of its resident population and the required resources to provide the care and services the residents need), dated July 17, 2024, revealed that the facility's training program includes an orientation process and ongoing training for all new and existing staff including managers, nursing, and other direct care staff, individuals providing services under contractual arrangement, and volunteers consistent with their expected roles. The content at a minimum included effective communication. Review of the education record for Nurse Aide 5 revealed a hire date of September 25, 2023. However, there was no documented evidence that she received the facility's education…

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

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure an assessment was completed by a professional (registered) nurse for a change in condition for one of five residents reviewed (Resident 1). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 20, 2024, revealed that the resident was cognitively intact and required assistance from staff for daily care needs. A nursing note for Resident 1, dated April 26, 2024, revealed that the resident 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 review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a professional licensure check prior to hire for one licensed practical nurse reviewed (Licensed Practical Nurse 1) and failed to complete a nurse aide registry check for one of three nurse aides reviewed (Nurse Aide 2). Findings include: The facility's abuse policy, dated December 7, 2023, indicated that the facility will conduct employee background checks and will not knowingly employ any individual who has had a finding entered into the nurse aide registry concerning abuse or neglect, or any individual that has a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse or neglect. Review of the personnel file for Licensed Practical Nurse 1 revealed that she was hired on October 11, 2023, and the Pennsylvania Professional Licensure check was not conducted until December 19, 2023, two months after she was hired. Review of the personnel file for Nurse Aide 2 revealed that she 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 review of clinical records and staff interviews, it was determined that the facility failed to ensure that the resident and/or responsible party was notified about the facility's bed-hold policy upon transfer to the hospital for one of 19 residents reviewed (Resident 3). Findings include: A nurse's note for Resident 3, dated August 16, 2023, at 4:01 p.m. revealed that the resident developed left facial drop and slurred speech and was transferred to the hospital. A nurse's note, dated August 17, 2023, at 6:41 a.m., revealed that the resident was admitted to the hospital. A nurse's note for Resident 3, dated September 24, 2023, at 8:32 a.m. revealed that the resident had a change in condition and had requested to be transferred to the hospital. A nurse's note, dated September 25, 2023, at 10:08 a.m., revealed that the resident was admitted to the hospital. There was no documented evidence that Resident 3 and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfers to the hospital. Interview with the Registered Nurse…

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

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans for individualized resident care needs for four of 19 residents reviewed (Residents 6, 17, 18, 22). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated October 10, 2023, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, was continent of bowel and urine, and had a significant weight gain. A review of Resident 6's clinical record revealed that the resident had a history of urinary tract infections. A physician's order for Resident 6, dated December 15, 2023, included an order for the resident to receive Cephalexin (an antibiotic) two times a day for a urinary tract infection until December 22, 2023. There was no documented evidence that a care plan was developed to address Resident 6's urinary tract infection with antibiotic treatment. An interview with the Registered Nurse Assessment Coordinator (RNAC)…

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

Based on review of clinical records and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for four of 19 residents reviewed (Residents 6, 9, 22, 40). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated October 10, 2023, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, was continent of bowel and urine, and had a significant weight gain. Observations of Resident 6 on December 18, 2023, at 11:15 a.m. revealed the resident was lying in bed. The resident stated she had not been out of bed for the last three to four weeks because staff had stated that the mechanical lift would not support her weight. Interview with the Registered Nurse Assessment Coordinator (RNAC) on December 19, 2023, at 2:00 p.m. revealed that Resident 6 was not able to get out of bed due to her weight exceeding the maximum weight limit of 450…

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

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to complete weekly wound assessments for one of 19 residents reviewed (Resident 8) and failed to notify the physician about a medication allergy for one of 19 residents reviewed (Resident 40). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated November 5, 2023, revealed that the resident was cognitively intact, required supervision with care needs, was at risk for developing pressure ulcers, had venous ulcers (ulcers caused by poor blood flow in leg veins), and had a diagnosis of peripheral vascular disease (a disease causing poor blood circulation to lower limbs). A care plan for Resident 8, revised on November 30, 2023, revealed that the resident had skin breakdown related to venous stasis ulcers of right ankle, right medial foot, right dorsal foot, and left dorsal foot. Interventions included to report evidence of infection such as purulent drainage, swelling, localized…

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

Based on review of clinical records and facility assessment reports, as well as staff interviews, it was determined that the facility failed to complete safety assessments for three of 19 residents reviewed (Residents 9, 17, 40) who used an air mattress. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated August 15, 2023, revealed that the resident was cognitively impaired, required extensive assist to total dependence with care needs, and was at risk for developing pressure ulcers. Observations on December 18, 2023, at 10:35 a.m. revealed that Resident 9 was lying in bed and the bed was equipped with an air mattress; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on the resident's bed. Interview with the Registered Nurse Assessment Coordinator (RNAC) on December 20, 2023, at 11:21 a.m. confirmed that there was no assessment for potential safety hazards prior to the air mattress being placed on…

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 19 residents reviewed (Resident 11, 15, 17). Findings include: The facility's policy regarding the administration of oral medications, dated December 7, 2023, indicated that the nurse will document on the Medication Administration Record (MAR) with their initials, at the appropriate date and time for the medication administered, after witnessing the ingestion of the medication. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated November 16, 2023, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included arthritis, high blood pressure, and chronic pain syndrome. Physician's orders for Resident 11, dated November 10, 2023, included an order for the resident to receive 10-325 milligrams (mg) of…

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

Based on review of policies, clinical records, and manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to properly secure and store medications in the medication carts and failed to properly label medications in the medication room. Findings include: The facility's policy regarding administering medications, dated December 7, 2023, indicated that the medication cart was to be kept closed and locked when out of site of the medication nurse, no medications were to be kept on top of the cart, and when opening a multi-dose container, the date opened was to be recorded on the container. Observations of a medication pass on December 19, 2023, at 7:40 a.m. revealed that Licensed Practical Nurse 4 left a card of Naproxen 500 milligram (mg) tablets and a card of Allopurinol 100 mg tablets on top of the medication cart unsupervised while he entered a resident's room to administer medication. Interview with Licensed Practical Nurse 4 at that time confirmed that he should not have left the medication on top of the cart…

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, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by not dating opened food items and not storing food under sanitary conditions. Findings include: The facility's policy regarding food storage, dated December 7, 2023, revealed that leftover food was to be stored in covered containers or wrapped carefully and securely. Each item was to be clearly labeled and dated before being refrigerated or frozen. All stock must be rotated with each new order received; new items were to be placed behind the supply in stock so that the oldest stock is always used first. Observations in the kitchen refrigerator on December 18, 2023, at 9:43 a.m. revealed an opened and undated package of lunch meat. Observations in the kitchen's walk-in refrigerator at 9:46 a.m. revealed a block of opened swiss cheese that was dated November 24, 2023, and three unopened containers of orange juice with a best by date of October 19, 2023. Interview with…

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

Based on review of hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for one of one hospice residents reviewed (Resident 19). Findings include: An agreement between the facility and a hospice provider (provider of end-of-life services) indicated that the hospice provider would provide information to the facility to facilitate coordination of care that included the most recent hospice plan of care specific to each patient and a hospice benefit of elections form (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness). Physician's orders for Resident 19, dated August 31, 2023, revealed that the resident was to receive hospice services from the facility's contracted hospice provider. As of December 20, 2023, there was no documented evidence in the resident's clinical record, or in the hospice provider'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 the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending February 1, 2023; complaint investigation surveys ending June 13, 2023, and September 20, 2023; and revisit surveys ending July 24, 2023, and October 30, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending December 20, 2023, identified repeated deficiencies related to care plan timing and revision, the failure to provide quality of care, safe environment free from accident hazards, storage and labeling 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 policies and clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to follow CDC guidelines to reduce the spread of infections and prevent cross-contamination related to an Extended Spectrum Beta-Lactamase (ESBL- Beta-lactamases are enzymes produced by some bacteria that may make them resistant to some antibiotics) infection in the urine for one of 19 residents reviewed (Resident 15). Findings include: The facility's Infection Prevention and Control policy, dated December 7, 2023, revealed that contact precautions are intended to prevent the transmission of infectious agents which are spread through direct or indirect contact with the patient or the patient's environment. Contact precautions also apply where the presence of excessive wound drainage, urine or fecal incontinence, or other discharges from the body suggest an increased potential for environmental contamination and risk of transmission. Enhanced barrier protections are intended to prevent transmission of multi-drug resistant organisms…

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the physician was notified about medications not being available for administration on multiple days for one of 10 residents reviewed (Resident 6). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated September 24, 2023, indicated that the resident was cognitively intact, required limited to extensive assistance from staff for daily care needs, was incontinent of bladder, and had diagnoses that included a urinary tract infection within the past 30 days and end-stage renal (kidney) disease. Physician's orders for Resident 6, dated September 14, 2023, included an order for the resident to receive 500 milligrams (mg) of cefuroxime axetil (antibiotic) twice a day for five days for a urinary tract infection. The Medication Administration Record (MAR) for Resident 6, dated September 2023, indicated that the resident did not receive cefuroxime axetil on September 14, 2023, at 8:00…

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

Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated regarding fall precaution interventions for two of 10 residents reviewed (Residents 3, 8) Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 2, 2023, indicated that the resident was cognitively intact, was independent with bed mobility and transfers, and had a history of falls. A nursing note, dated August 12, 2023, at 3:41 p.m. revealed that Resident 3 was observed sitting in his wheelchair in the bathroom. Blood was noted on the floor next to his bed, on his bed sheets, and on his clothing. A laceration was observed on the resident's forehead that measured 9.0 x 0.5 centimeters (cm) as well as a skin tear on his right forearm. When asked what happened, the resident stated he was sitting on his bed and leaned over to reach for something and fell off the bed and hit his head on the floor. He then got himself up into his…

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 records reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for one of 10 residents reviewed (Resident 6). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated September 24, 2023, indicated that the resident was cognitively intact, required limited to extensive assistance from staff for daily care needs, was incontinent of bladder, and had diagnoses that included a urinary tract infection within the past 30 days and end-stage renal (kidney) disease. Physician's orders for Resident 6, dated September 14, 2023, included an order for the resident to receive 500 milligrams (mg) of cefuroxime axetil (antibiotic) twice a day for five days for a urinary tract infection. The Medication Administration Record (MAR) for Resident 6, dated September 2023, indicated that the resident did not receive cefuroxime axetil on September 14, 2023, at 8:00 a.m. and 8:00 p.m. and September 18, 2023, at 8:00…

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

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to attempt new interventions for fall prevention for one of the 10 residents reviewed (Resident 3) and failed to ensure that fall prevention interventions were in place as ordered for one of 10 residents reviewed (Resident 8). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 2, 2023, indicated that the resident was cognitively intact, was independent with bed mobility and transfers, and had a history of falls. A nursing note, dated June 24, 2023, at 4:45 a.m. revealed that Resident 3 was found on the floor with both legs bent at the knees. He said that he was getting out of bed and slid down to his knees. He had an abrasion on the left knee measuring 4.0 x 3.0 centimeters (cm) and two abrasions noted on the right knee measuring 1.0 x 1.0 cm and 4.0 x 2.5 cm. There was no documented evidence that any new interventions were put into place to prevent falls for…

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

Based on clinical records reviews and staff interviews, it was determined that the facility failed to ensure that a resident's clinical record was complete and accurately documented for one of 10 residents reviewed (Resident 6). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated September 24, 2023, indicated that the resident was cognitively intact, required limited to extensive assistance from staff for daily care needs, did not receive bathing during the review period, and received dialysis. Physician's orders, dated July 12, 2023, revealed that the resident received dialysis every Tuesday, Thursday and Saturday. A shower/bathing record, dated December 21, 2022, revealed that Resident 6 was to receive a bath/shower during the evening on non-dialysis days. Nurse aide documentation for August and September 2023 revealed no documented evidence that Resident 6 received a shower from August 1 through 14 and September 1 through September 7, 2023. Interview with Resident 6 on September 20,…

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

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices during care for one of 10 residents reviewed (Resident 8). Findings include: The facility policy for handwashing/hygiene, dated November 17, 2022, indicated that the use of gloves do not replace handwashing/hygiene. Hand hygiene is the final step after removing and disposing of personal protective equipment. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 5, 2023, revealed that the resident was frequently incontinent of bowel and bladder and required extensive assistance of two for hygiene. Physician's orders for Resident 8, dated September 6, 2023, indicated that she had a pressure ulcer on her right and left buttocks and the wounds were to be cleaned with soap and water, apply zinc, and then apply a foam dressing three times a day and as needed. Observations of Resident 8 during hygiene and wound care 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.