Linwood Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of employee personnel records, review of facility policies and procedures, and staff interviews, it was determined the facility failed to develop, implement, and maintain an effective training program to ensure licensed nursing staff possessed the knowledge and competencies necessary to safely manage a peripherally inserted central catheter (PICC line) for 1 resident (Resident 102) of 16 residents reviewed who required care involving a PICC line.Findings include:Federal regulation requires that a facility develop, implement, and maintain an effective training program for all new and existing staff. The facility must use the facility assessment, which is an evaluation the facility conducts to identify the resident population served to determine the amount and types of training necessary to ensure staff competencies meet the needs of the residents as identified in their care plans and the facility assessment. Clinical record review revealed Resident 102 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to ensure the resident environment was free from potential accident hazards for one out of four nursing units observed (300 Hall), including observations made of one out of 14 residents' rooms (Resident 1).Findings included: A review of facility policy titled Medication Administration Practice Recommendations, last reviewed by the facility on August 14, 2025, revealed it is facility policy that a nurse or qualified staff should stay with the resident until medication has been taken. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function). A physician's order for Tylenol tablet 325 mg (acetaminophen-a pain-relieving medication) with directions to give two tablets by mouth every four hours as needed for mild pain was initiated on April 2, 2025. A physician's order…

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, the facility failed to ensure adequate monitoring of behaviors and potential adverse consequences prior to administering psychoactive medications for one of 10 residents reviewed (Resident 2). Findings include: Review of Resident 2's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included anxiety disorder (a group of symptoms, such as stress, anxiety, feeling sad or hopeless, and physical symptoms that can occur after you go through a stressful life event), encephalopathy ( a medical condition characterized by a general dysfunction of the brain that affects cognitive function, consciousness, and behavior), and chronic pain. Review of a quarterly Minimum Data Set Assessment (MDS-a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated April 14, 2025, indicated the resident had a BIMS (brief interview mental screener that aids in detecting cognitive…

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

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Review of a facility policies titled Refrigerator and Frozen Food Storage last reviewed by the facility on February 18, 2025, indicated that all TCS (time, temperature, control foods)…

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 document review, clinical record review, and staff interviews, it was determined that the facility failed to timely provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) to notify one of three residents reviewed (Resident 95) that Medicare Part A coverage for skilled nursing services was ending. Findings Include: A review of Resident 95's clinical record revealed admission to the facility on December 9, 2024, with diagnoses to include fusion of the spine (a surgical procedure that connects two or more vertebrae in the spine to eliminate movement between them, providing stability and pain relief). Review of the resident's Medicare coverage documentation revealed the last day of covered Medicare Part A services was February 24, 2025. Further review revealed the facility did not issue the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) form to Resident 95 until February 25, 2025, after Medicare Part A coverage had ended. An interview conducted with the Director of Social Services on May 19, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, the Resident Assessment Instrument (RAI), and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments accurately reflected the status of one resident out of 21 sampled (Resident 72). Findings include: According to the Resident Assessment Instrument (RAI) User's Manual (an assessment tool utilized to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan, and the RAI also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status) dated October 2024, Section N Medications Subsection N0350A: Insulin, indicate the number of days during the 7-day look-back period that the resident received insulin (a hormone medication used to treat diabetes) injections. A clinical record review revealed Resident 72 was admitted to the facility on [DATE]. A review of a quarterly Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and interviews with staff, it was determined the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight, unless the resident's clinical condition demonstrates that is not possible, for one out of 21 residents sampled (Resident 51). Findings include: A facility policy titled Weighing of Residents, last reviewed by the facility on February 18, 2025, revealed it is the facility's policy to monitor residents' weight to detect significant weight loss or gain in order to ensure that the resident maintains acceptable parameters of nutritional status. The policy indicates if the resident exhibits a weight change of 5 lbs from the previous weight, the resident shall be re-weighed within 24 hours and the re-weighing shall be recorded. If the re-weight is validated as a 5% change, the registered dietician completes an assessment to investigate the cause of the weight change. The policy states the charge nurse will notify the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, the facility's abuse prohibition policy, information provided by the facility, and staff interviews, it was determined that the facility failed to promptly conduct a thorough investigation to rule out abuse and implement corrective action for one of 6 residents reviewed (Resident 4). Findings included: A facility policy entitled Allegation, Suspicion, or Witnessed Abuse, Neglect, Misapplication, or Exploitation Intervention and Reporting, last reviewed by the facility on May 10, 2024, indicated that staff will immediately report the incident to the Charge Nurse or immediate supervisor of the area. Upon receiving a report of abuse or alleged abuse, the Charge Nurse or supervisor or the area shall immediately notify the RN Supervisor, who will respond to the location, examine the resident, and begin the investigation. The following information should be included in the initial verbal and subsequent written report: name of the resident(s) involved, the date and time of the…

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

Based on observation and staff interview it was determined the facility failed to protect the personal privacy rights of three of 28 residents sampled (Resident A1, A2, and A3). Findings include: An observation of Resident A1's room on September 5, 2024, at 9:45 AM, revealed a sign was taped above the resident's bed indicating the resident was to have a Hoyer pad under her while in her wheelchair. An observation of Resident A2's room on September 5, 2024, at 9:49 AM, revealed a sign was taped above the resident's bed indicating the resident is to have nectar thicken liquids only. An observation of Resident A3's room on September 5, 2024, at approximately 9:55 AM revealed signs taped above the resident's bed indicating the resident was to have nectar thick fluids and no over the bed table. Interview with the Nursing Home Administrator (NHA) on September 5, 2024, at approximately 5:15 PM revealed that the NHA was unable to provide information regarding the reason for these signs posted behind the residents' beds, that failed to assure the residents' personal privacy. 28 Pa. Code…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff and resident interview, it was determined the facility failed to provide adequate supervision to prevent a fall and promote resident safety for two of 28 sampled (Resident's B1 and A 10). Findings include: A review of the clinical record revealed that Resident B1 was admitted to the facility on [DATE], with diagnoses to include cerebral infarction(stroke). A review of an admission minimum data set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 23, 2024 revealed the resident was cognitively intact, with a BIMS score ( Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment.) of 15 ( a score of 13 to 15 indicates cognitively intact) and required staff assistance for transferring and toileting. A review of a facility investigation report dated September 1, 2024 at 8:00 PM revealed staff 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility's plan of correction from the survey ending July 23, 2024, the outcome of the activities of the facility's quality assurance committee, observations and interviews it was determined the facility's procedures failed to effectively identify ongoing deficient practices related to personal privacy and infection control. Findings include: As a result of the deficiencies cited under the requirements related to personal privacy, accident hazards infection control, and facility staffing during the survey of September 5, 2024, the facility developed a plan of correction to serve as their allegation of compliance, which included a quality assurance monitoring component to ensure that solutions were sustained. This corrective plan was to be completed and functional by August 12, 2024. However, during the survey ending September 5, 2024, continuing deficient facility practice was identified with these same requirements. According to the facility's plan of correction for the deficiency cited…

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 facility's infection control tracking log and staff interview, it was determined the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility and failed to maintain infection control practices to prevent the spread of infections regarding foley catheter maintance for 1 of 28 sampled residents. (Resident 7). Findings include: A review of the facility's policy entitled Infection Control Policies and Practices (not dated), conducted during the survey ending September 5, 2024, revealed the facility's infection control policies are intended to facilitate maintaining a safe sanitary comfortable environment and help prevent and manage transmission of disease and infection. A review of the facility's infection control data provided during the survey of September 5, 2024, revealed the facility's infection control program failed to reflect an operational system to monitor and investigate causes of infection and the manner of spread. There…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, review of facility documentation and interviews with staff and residents it was determined the facility failed to efficiently deploy sufficient nursing staff to provide timely and quality care to each resident including one residents out of 28 sampled (Resident B1). Findings include: A review of the clinical record revealed that Resident B1 was admitted to the facility on [DATE], with diagnoses to include cerebral infarction(stroke). A review of an admission minimum data set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 23, 2024 revealed the resident was cognitively intact, with a BIMS score of 15 ( Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment a score of 13 to 15 indicates cognitively intact) and required staff assistance for transferring and toileting. A review of a facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined the facility failed to maintain an environment free of potential accident hazards on one of two floors (second floor). Findings include: Observation on July 23, 2024 from 9:00 AM through 2:30 PM the following: On the second floor unit residents were observed ambulating in the hallways and and self-propelling in wheelchairs. At this time two air purifier units were plugged into wall outlets on each side of the hallway near resident room [ROOM NUMBER] and 13. The units were not secured, and moveable and obstructed continued access to the handrails on that side of the corridor and also not secured in any manner to prevent tipping. The cords and plugs created a potential tripping hazard. A plastic container with three drawers was observed in the hallway near room [ROOM NUMBER], which contained rubber gloves, protective gowns and masks, obstructing access to the handrail An air purifier unit was observed plugged into the wall outlet in the 200 hallway near…

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

Based on review of the facility's infection control tracking log and staff interview, it was determined the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility. Findings include: A review of the facility's policy entitled Infection Control Policies and Practices (not dated), conducted during the survey ending July 23, 2024, revealed that the facility's infection control policies are intended to facilitate maintaining a safe sanitary comfortable environment and help prevent and manage transmission of disease and infections. A review of the facility's infection control data provided during the survey of July 23, 2024, revealed that the facility's infection control program failed to reflect an operational system to monitor and investigate causes of infection and manner of spread. There was no evidence of a functional system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner. A review of facility monthly infection control logs for June…

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 protect the personal privacy rights of one of six residents sampled (Resident 1). Findings include: During an observation of Resident 1's room on July 23, 2024 at approximately 10:15 AM a hand written sign was observed taped to the back of the resident's bed which read R Limb alert (RUE) NO IV, lab draws, BPs or tight clothing. Interview with Resident 1 and her daughter on July 23, 2024, at 10:20 AM revealed that they did not know why that sign was posted behind the resident's bed. They stated they did not put the sign there, the facility did. When asked Resident 1 stated there was no reason that they could not use her right arm. She stated no one ever mentioned to her that her right arm should not be used. Resident 1 then asked if the sign could be removed from the wall behind her bed. A review of the resident's clinical record indicated her right arm should not be used for blood draws, but did not identify the clinical reason or diagnosis. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and resident and staff interview, it was determined that the facility failed to ensure that a resident's comprehensive care plan included the care the resident required to attain the resident's highest practical physical well-being for one resident out of six reviewed (Resident 1). Findings including: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include a displaced fracture of the right lower leg (broken ankle) with history of falls. An interview and observation of Resident 1 at 10:00AM on July 23, 2024, revealed that the resident had a blue hard cast on her right leg, that extended from the base of her toes to just below her knee. A review of the resident's current plan of care initially, dated May 30, 2024, revealed that the presence of the cast or the need for assessment of her exposed toes to ensure that adequate color, circulation, sensation and mobility was present without swelling, was not included on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of practice for one resident (Resident 1) out of six residents reviewed by failing to assure prompt and necessary treatment for treatment for a resident's complaints of physical discomfort, painful urination, which delayed diagnosis and treatment of a salmonella infection. Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.292a. CRNP (Certified Registered Nurse Practitioner) Practice (b)(1)(2) indicates (b) When acting in collaboration with a physician as set forth in a collaborative agreement and within the CRNP's specialty, a CRNP may: (1) Perform comprehensive assessments of patients and establish medical diagnoses. (2) Order, perform and supervise diagnostic tests for patients and, to the extent the interpretation of diagnostic tests is within the scope of the CRNP's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review clinical records and facility documentation and interviews with residents and staff it was determined that the facility failed to demonstrate that its quality assurance program fully investigated and analyzed causes of adverse events, a resident's diagnosed salmonella infection, to evaluate the adequacy of the facility's response to the foodborne illness and implement any applicable performance improvement activities. Findings included: Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with a diagnosis of a fractured ankle. An interview with Resident 1 on July 23, 2024, at 10:00 AM revealed she had concerns with food served at the facility. She stated the food the food served was extremely salty. She stated that she received food items that she disliked, including soft cooked eggs, egg whites, baloney sandwiches and a variety of other foods prepared by the facility that were not to her liking. She stated she also received greasy…

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 staff interviews and a review of facility training and orientation records, it was determined that the facility failed to ensure that all employees received training on the facility's abuse prohibition policy and facility specific-procedures. Findings include: During an interview with the Nurse Educator on June 28, 2024, at 10:00 a.m., revealed that the facility utilizes an on-line education platform for staff to complete mandatory education and additional education topics were provided as needed on paper and offered a variety of educational methods present topics. The Nurse Educator provided the educational content on which staff received for their annual abuse prevention education program. The education failed to include the facility's specific procedures for identifying and reporting abuse, neglect, exploitation, or misappropriation of resident property or resident abuse prevention. During an interview on June 28, 2024, at 11:15 a.m., the Nursing Home Administrator (NHA) stated that prior to survey that it was identified that the mandatory annual abuse training and 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 a review of clinical records and the facility's abuse prohibition policy, and staff interviews, it was revealed that the facility failed to promptly report instances of resident abuse to the State Survey Agency, and submit completed abuse investigations to the State Survey Agency within five working days of the incident, for three out of four allegations of abuse reviewed. Findings include: A review of a policy entitled Abuse Prevention Program last reviewed by the facility on May 10, 2024, indicated that the facility will report alleged and substantiated incidents to the Pennsylvania Department of Health, additional state agencies and/or local authorities per federal and state requirements. The facility will analyze the occurrences to determine what changes are needed, of any, to policies and procedures to prevent further occurrences. Any report or allegations of abuse/neglect, misappropriation, or exploitation will be reported initially by the Administrator (NHA), Director of Nursing (DON), Assistant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, the facility's abuse prohibition policy and information provided by the facility it was determined the facility failed to promptly conduct a thorough investigation into instances of sexual abuse, protect other female residents from the potential for further abuse during the investigation and submit the completed investigation to the State Survey Agency within five working days of the incident as evidenced by one of 14 residents reviewed (Resident 8) and failed to thoroughly investigate injuries of unknown origin, ankle fracture, to rule out abuse, neglect or mistreatment as the potential cause for one out of 21 sampled residents (Residents 48). Findings included: A review of the facility's Abuse Policy that was last reviewed by the facility on May 10, 2024, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Sexual abuse is non-consensual sexual contact of any type…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility policy, staff, and resident interviews, it was determined that the facility failed to provide written notice of the facility's bed hold policy to a resident and the resident's representative upon the resident's transfer to the hospital for six residents out of the 21 sampled (Residents 2, 7, 24, 53, 72, and 188). Findings include: A review of the clinical record revealed that Resident 2 required transfer to the hospital on January 13, 2024, and was readmitted to the facility on [DATE]. Further clinical record review revealed no documentation that Resident 2 or Resident 2's representative were made aware of a facility's bed-hold and reserve bed payment policy upon transfer to the hospital. A review of the clinical record revealed that Resident 53 required transfer to the hospital on May 5, 2024, and was readmitted to the facility on [DATE]. Further clinical record review revealed no documentation that Resident 53 or Resident 53's representative were made…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy and investigative reports and staff interviews it was determined that the facility failed to fully assess and implement individualized measures planned for the toileting needs of three residents out of 5 sampled for a decline in continence (Residents 51,15, and 2). Findings included: A review of a facility policy entitled Bladder and Bowel Screening and Assessment that was last reviewed by the facility May 10, 2024, indicated that a resident's bladder and bowel status will be evaluated and assessed at the time of admission/readmission and as needed with a change in bladder and bowel status. A plan of care is initiated based on the findings of the evaluation/assessment and/or voiding pattern diaries. The procedure included a minimum of three consecutive days (if appropriate), to identify the type of bladder/bowel incontinence and develop a bowel/bladder program as indicated. Upon completion of a bladder and bowel diary, the findings will be reviewed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility policy, and staff interviews, it was determined that the facility failed to consistently and accurately monitor resident weights to timely identify changes in nutritional parameters for three residents out of 21 sampled (Residents 21, 7, and 53). Findings included: A review of facility policy titled Weighing of Residents, last reviewed by the facility on May 10, 2024, revealed the facility must monitor the resident's weight to detect significant weight loss or gain in order to ensure that the resident maintains acceptable parameters of nutritional status, taking into account the resident's clinical condition or other appropriate intervention when there is a nutritional problem. The policy indicates that if the resident exhibits a weight change of 5 pounds from the previous weight, the resident shall be re-weighed within 24 hours, and the re-weight shall be recorded. Furthermore, the policy indicates that if the weight change falls into the significant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interviews it was determined that the facility failed to develop and implement individualized pain management program, consistent with professional standards of practice, to meet the pain management needs of one of 21 residents reviewed (Resident 48). Findings include: According to the US Department of Health and Human Services, Interagency Task Force, Executive Summary Report dated May 2021, for Pain Management Best Practices the development of an effective pain treatment plan after proper evaluation to establish a diagnosis with measurable outcomes that focus on improvements including quality of life (QOL), improved functionality, and Activities of Daily Living (ADLs). Achieving excellence in acute and chronic pain care depends on the following: · An emphasis on an individualized patient-centered approach for diagnosis and treatment of pain is essential to establishing a therapeutic alliance between patient and clinician. · Acute pain can be caused by a variety of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined that the facility failed to ensure the provision of consistent and timely physician services for one of 21 sampled residents (Resident 48). Findings include: A review of Resident 48's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis (a chronic autoimmune disease that causes inflammation and damage to the body's joints and other tissues), Alzheimer's disease, age-related osteoporosis (a bone disease that causes bones to become fragile due to a decrease in bone mass and density). A nurse's note dated February 17, 2024, at 2:07 PM indicated that the resident's family approached the nurse, concerned over swelling of the resident's left leg and requested results of the x-ray that was performed on February 5, 2024. According to the note, a call was placed to the physician, and message left. Nurse's note dated February 18, 2024, at 1 PM indicated that a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility policies and interviews with staff and residents it was determined that the facility failed to provide sufficient nursing staff to provide timely and quality care to each resident including three residents out of 21 sampled (Resident 7, 21, 80). Findings included: A review of facility policy titled General Dose Preparation and Medication Administration, reviewed last by the facility on May 10, 2024, revealed that during medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to, the following: administer medications within timeframes specified by facility policy or manufacturer's information. A clinical record review revealed Resident 7 was admitted to the facility on [DATE], with diagnoses that include atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal), cardiomyopathy (a disease of the heart muscle that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility policy, and staff interview it was determined that the facility failed to provide sufficient staff, involved in the direct care of residents, who possess the appropriate skills and competencies to promptly identify and address an escalation in inappropriate sexual behaviors displayed by one resident (Resident 8) out of 21 sampled to maintain the safety and well-being of other residents. Findings included: A review of Resident 8's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included unspecified dementia and adjustment disorder (difficulty in managing stressful life changes such as coping with work-related problems, loss of loved ones, or relationship issues that leads to significant impairment in functioning) with mixed disturbance of emotions and conduct. The resident had severe cognitive impairment. A review of Resident 8's plan of care dated June 25, 2023, and revised on March 26, 2024, revealed…

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

Based on a review of the facility's assessment, select facility policies and procedures, and resident clinical records, staff and resident interviews, the facility failed to document a facility-wide assessment to identify the resources needed to meet the residents, including sufficient staff with the necessary skills and competencies to provide the needed care and services for residents with behavioral health care and dementia care needs. Findings include: The facility assessment, dated Quarter 1 2024, and reviewed during the survey ending June 28, 2024, revealed the facility's census and acuity and general information regarding the facility's religious denominations, recreation, social services and physical, occupational and speech therapy services. The facility assessment did not include evidence of an evaluation of diseases, conditions, physical, functional or cognitive status, of the residents that may affect and plan for the services the facility must provide for residents with behavioral health care and dementia care needs. The facility assessment failed to include the…

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

Based on review of facility QAPI meeting attendance records and staff interviews, it was determined the facility failed to ensure that the required committee members met at least quarterly for one quarter out of three reviewed. Findings include: An interview was conducted with the Nursing Home Administrator (NHA) on June 28, 2024, at approximately 12:30 p.m., revealed that facility's QA/QAPI committee members included the Administrator (NHA), Director of Nursing (DON), Medical Director, and department heads. The NHA reported that the committee should meet at least quarterly. Review of the facility's QA/QAPI committee attendance sheets for the QA meetings held since the last annual survey ending July 23, 2023, through annual survey ending June 28, 2024, revealed that the QA/QAPI committee only held one quarterly meeting that was conducted on April 30, 2024. Interview with the NHA, at approximately 12:33 p.m., reported that she was unable to locate the QA/QAPI signature sheets to show documented evidence that the facility's QA/QAPI committee met at least quarterly. 28 Pa. Code 201.18…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one of 21 sampled residents (Resident 12). Findings include: According to the RAI User's Manual regarding Section N0410 for Medications Received, the facility would record the number of days a medication was received by the resident at any time during the 7-day look back period. A review of Resident 12's quarterly MDS assessment dated [DATE], Section N 410 indicated that the resident received an anticoagulant medication 7 days in the 7 day look back period. A review of the Resident 12's physician orders revealed that the resident did not have a physician order for an anticoagulant medication during the 7 day look back period. Review of the resident's May 2024 and June 2024 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 observation and staff interview, it was determined that the facility failed to maintain an environment free of potential accident hazards on one of three resident care units (300 Hall). Findings include: Observations made during medication administration on June 28, 2024, at approximately 8:30 AM revealed an unattended, and unlocked, medication cart in the hallway of the resident unit. During observation of resident medication administration with Employee 10, licensed practical nurse, the medication cart was left unlocked and unattended when Employee 10 took medications into a resident room to administer to resident. The cart was left against the wall across from where the resident's room was located and out of the nurse's view. Further observation of the medication cart revealed that the keys to the cart, which allow access to both the medication cart and narcotic drawer within, were left unattended on top of the cart. Multiple residents were observed ambulating/self-propelling out in the hallway at the time of this observation. During an interview with the Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and resident and staff interviews, it was determined that the facility failed to timely provide dental services required by one Medicaid Payor source resident out of the 21 sampled residents (Resident 7). Findings include: A clinical record review revealed Resident 7 was admitted to the facility on [DATE], with diagnoses that include atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal), cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), and heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 23, 2024 revealed that Resident 7 is cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status- a tool within 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 observations, a review of facility's planned meal tickets, a review of clinical records, and resident and staff interviews, it was determined that the facility failed to accommodate resident's food allergies and provide weight loss interventions for one resident, Resident 53, out of 21 residents reviewed. Findings include: A review of a facility policy entitled Supplements that was last reviewed on May 10, 2024, revealed that if maintenance of acceptable nutritional status is difficult through delivery/intake of regular meals, the facility will consider and provide the resident with additional nourishment through between-meal or dietary supplements. A nutritional assessment will be completed to determine the need and appropriateness of dietary supplement use and a physicians' order for a dietary supplement will be obtained and maintained in the medical record. Dining services will provide supplements as ordered and nursing will document the acceptance of supplements in the electronic ADL (activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and review of select facility policy and staff interview, it was determined that the facility failed to maintain infection control practices during administration of resident medication by one nurse out of two observed administering medications (Employee 10). Findings include: Review of facility policy entitled General Dose Preparation and Medication Administration, last reviewed by the facility on May 10, 2024, indicated that appropriate hand hygiene should be performed before and after direct resident contact. Medications should not come in contact with any surface except for the medication cup. Facility staff should avoid touching the medication with bare hands when opening a bottle or unit dose package. During an observation of medication administration on June 28, 2024, at approximately 8:15 AM., with Employee 10, licensed practical nurse, Employee 10 was observed preparing medications for administration to a resident. Employee 10 was observed handling each medication, nine in total,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policy, and the facility's infection assessment tool, and staff interview it was determined that the facility failed to consistently implement its antibiotic stewardship protocols for initiating antibiotic use for two residents out of 21 sampled. (Resident 2 and Resident 188) Findings included: Review of a facility policy entitled Antibiotic Stewardship last reviewed May 10. 2024, indicated it was the policy of the facility to provide optimal use of antibiotics based on clinical guidelines and avoided unnecessary adverse events related to the use of medications. Goals of the program were to provide a clearly defined empiric therapy for treatment of suspected infections when appropriate, promote safe and effective use of antibiotics that will adequately treat the patient for susceptible bacterial infections, and to change broad spectrum antibiotics to promote narrowed therapy to minimize bacterial resistance in the facility and community. The facility will utilize…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, and staff interviews, it was determined that the facility failed to timely notify a resident's responsible representative of injuries sustained by one resident out of eight sampled (Resident A1). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. A review of Resident A1's clinical record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy and fall reports and staff interview it was determined that the facility failed to consistently implement planned fall prevention interventions for a resident identified a high risk for falls for one resident out of eight sampled (Resident B1). Findings included: A review of Resident B1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included rhabdomyolysis [a breakdown of skeletal muscle due to direct or indirect muscle injury and left untreated can result in kidney damage], history of falling, and Alzheimer's disease [is a type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition]. A review of the resident's initial fall risk evaluation dated May 1, 2024, at 9:30 p.m., identified that the resident was a high fall risk related to falling 1-2 times over the last six-months, and never oriented to person, place, time, or situation,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined that the facility failed to assure timely and completely documented clinical records, according to professional standards, for one of eight sampled residents (Resident A1). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. A review of Resident A1's clinical record revealed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to thoroughly assess and evaluate bowel and bladder function and implement individualized approaches to restore normal bowel and bladder function to the extent possible for three out of six sampled residents (Resident CR1, 2, and 3). Findings include: Review of the facility policy entitled Bowel and Bladder Retraining and Scheduled Toileting Program dated as reviewed by the facility on May 26, 2023, revealed indicated that at the time of admission, all resident's evaluation status would be assessed to identify potential risk factors and initial potential for bladder re-training or scheduled toileting. Within 24-hours of admission, a voiding pattern will be initiated, and a preliminary care plan will be initiated based on the initial assessment. The goal is to collect data to assist in determining resident's potential for re-training, or to establish a toileting regimen. The Voiding…

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 clinical records, and staff interview, it was determined that the facility failed to timely consult with the physician regarding a significant change in mental status and behavioral symptoms displayed by one resident out of six sampled (Resident CR1). Findings include: A review of facility policy entitled Change is Resident Condition/Notification revealed the facility must evaluate each resident's change in condition and notify the attending physician. Further it was indicated the physician will be notified of an abrupt onset of agitation or behavioral disturbance change from the resident's usual behaviors. A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses which included acute kidney failure, retention of urine, and cerebral infarction (stroke). A review of a nursing note dated for November 17, 2023, at 10:10 AM revealed the resident the resident was alert, awake, and making his needs known. A 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and select facility policy and staff interview, it was determined that the facility failed to maintain accurate and identifiable clinical records for one of six sampled residents (Resident CR1). Findings include: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses which included acute kidney failure, retention of urine, and cerebral infarction (stroke). A review conducted on December 5, 2023, of an admission physician progress note dated November 18, 2023, revealed that the physician's documentation was illegible. The documentation could not be read or understood by facility staff and the results of the physician's assessment of the resident could not be determined that nor any directions or recommendations that the physician may have given for the resident's care upon admission. During an interview with the DON (director of nursing) on December 5, 2023, at 10:20 AM the DON attempted to read the physician's progress…

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.